This position sits within the Agency’s Office of General Counsel, with at least monthly direct reporting to the Agency’s CEO/President, and quarterly reporting to the Compliance Committee of the Agency’s Board of Directors, with regard to agencywide risk assessment matters.
The person filling this position is expected to ensure appropriate and effective monitoring of existing procedures of program operations and delivery of services from both legal and regulatory compliance and quality assurance frameworks. This includes but is not limited to, collaborating with all levels of management and documenting program compliance and effectiveness, and initiating an agencywide risk assessment and quality improvement plan.
Conduct internal program audits and risk assessments to ensure compliance with regulatory standards and assist in establishing methods to improve program’s efficiency and quality of services, as well as reduce vulnerability to fraud, waste and abuse.
Ensure funder and/or oversight entity program operational requirements are adhered to and collaborate with management on the provision of quality services. Conduct site visits and workshops, which may include observing staff interaction with participants such as intakes, service plan creation, and reviewing case files for completeness, accuracy, and compliance.
Record, aggregate, analyze and report results of program activity audits, identifying trends and root causes, and making recommendations for program or performance improvements.
Identify gaps in program and staff performance and recommend, develop and/or conduct staff training to cure deficiencies and reiterate standards and enhance service practices.
Create Standard Operating Procedures (SOPs) and/or Desk Guides for new and existing programs as needed.
Assist with external audits conducted by funders and third-party auditors.
Report, escalate and/or investigate matters related to the program compliance, independent of any program interest in protecting its billing outcomes, including designing and coordinating internal investigations, and documenting, reporting, coordinating and pursuing any resulting correction action.
Meet with the senior staff of programs under review to discuss any findings and implement changes and work collaboratively with program department management, external agencies and stakeholders to support compliance efforts and monitor remediation (Corrective Action) activities.
Develop and maintain an annual report that provides an agency wide risk assessment, in at least general terms, as well as a thorough description of CAMBA’s Quality Assurance activities with an established Quality Improvement Plan (QIP) model.
Develop and implement quality assurance tools to measure and assess the impact of systems, policies and protocols on operational efficiencies and program effectiveness.
Prepare monthly and/or quarterly reports as appropriate for Senior Leadership and regulatory bodies.
Report directly on a regular basis but no less frequently than quarterly to CAMBA’s board-level Compliance Committee, including to CAMBA’s CEO/President and the Board Member Compliance Committee Chair.
Participate in team meetings.
Communicate with peers on agency-wide issues and best practices.
Lead and/or participate in special projects related to areas of oversight as needed.
Ensure the accuracy and timeliness of all weekly/monthly/quarterly/semester/annual reports and statistical information required for each department as needed for both CAMBA Executive Staff and funders.
Build (and encourage staff in building) open, honest, trustworthy relationships with referral sources, clients, staff, peers, funders, outside agencies, and the community.
Confer with Chief Legal Officer and CEO/President, as well as CAMBA Executive/Leadership Staff for programs and departments under review, as needed regarding legal and regulatory compliance and quality assurance matters.
Immediately reports to immediate supervisor and/or other appropriate CAMBA Executive Staff as needed regarding any monitoring visits, funder events, other significant events, and any incident that might subject CAMBA to liability.
Comply with all Federal, State, City and CAMBA security and privacy polices intended to protect the security and privacy of CAMBA proprietary information, client and staff personal identifiable information (PII) and personal health information (PHI).
Other duties as assigned.
