Essential Responsibilities:
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Provide technical assistance and training to program staff regarding documentation standards, quality assurance findings, privacy requirements, and compliance expectations.
- Collaborate with program leadership to develop corrective action plans and quality improvement strategies.
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Assist program leadership in preparing for external monitoring visits, audits, accreditation reviews, and funder compliance assessments.
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Conduct client chart reviews and internal audits.
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Assist in the development and implementation of Continuous Quality Improvement (CQI) initiatives across agency programs.
- Monitor trends identified through audits, chart reviews, and compliance activities and recommend corrective or preventive actions.
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Assist in the development, review, and maintenance of agency policies, procedures, forms, and compliance documentation.
- Monitor agency practices for alignment with established policies and contractual requirements.
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Monitor compliance with HIPAA and privacy standards.
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Support file retention and records management requirements.
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Develop quality assurance reports and audit summaries.
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Assist with corrective action planning and implementation.
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Other duties as assigned.
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Demonstrated improvements in documentation quality, compliance outcomes, or program performance through quality improvement activities.
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Timely completion of audit schedules.
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Accurate quality assurance reporting.
Successful implementation of corrective action plans.
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Master's degree in Public Health, Social Work, Healthcare Administration, Public Administration, Psychology, Sociology, or related field.
- Minimum two (2) years of quality assurance, compliance, or quality improvement experience required; three (3) years preferred in public health, nonprofit, behavioral health, healthcare, or community health center settings.
- Knowledge of HIPAA, privacy, confidentiality, records retention, documentation standards, and regulatory requirements applicable to nonprofit human service organizations.
- Demonstrated experience developing, writing, reviewing, updating, and implementing policies, procedures, protocols, forms, and operational guidelines.
- Experience interpreting contractual, regulatory, funding, and organizational requirements and translating them into practical operational procedures.
- Experience preparing for, participating in, and responding to internal and external audits, monitoring visits, compliance reviews, accreditation activities, or similar quality assurance processes.
- Experience analyzing and synthesizing information from multiple sources, including contracts, grant agreements, regulations, policies, and program requirements, to support organizational compliance and quality improvement efforts.
- Demonstrated exceptional attention to detail, accuracy, and organization, including the ability to identify documentation deficiencies, compliance concerns, procedural inconsistencies, and potential risks.
- Ability to review, analyze, and prepare audit findings, quality assurance reports, corrective action plans, compliance recommendations, and other related documentation.
- Strong technical writing skills, including the ability to prepare policies, procedures, reports, training materials, and compliance-related documentation.
- Experience conducting client chart reviews, documentation reviews, and internal audits.
- Knowledge of file retention standards, records management practices, and documentation requirements.
- Experience and proficiency utilizing electronic records systems, databases, reporting platforms, and Microsoft Office applications, including Excel.
- Strong analytical, organizational, written, and verbal communication skills.
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Ability to identify operational, compliance, documentation, contractual, and programmatic risks and recommend appropriate mitigation strategies.
- Knowledge of quality assurance, compliance monitoring, and continuous quality improvement (CQI) methodologies.
- Ability to conduct audits, chart reviews, compliance assessments, and documentation reviews with a high degree of accuracy and attention to detail.
- Strong analytical and problem-solving skills, including the ability to evaluate data, identify trends, and develop actionable recommendations.
- Ability to provide technical assistance, training, and coaching to program staff regarding quality assurance, documentation, and compliance requirements.
- Flexibility to work across multiple program divisions supporting a variety of service models, funding sources, and regulatory requirements.
- Strong written and verbal communication skills, including the ability to prepare reports, present findings, and communicate recommendations effectively.
- Ability to establish and maintain collaborative working relationships while effectively communicating compliance findings, recommendations, and corrective actions.
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Proficiency in electronic records systems, databases, and Microsoft Office applications, including Excel and data reporting tools.
