The Carroll County Youth Services Bureau is a non-profit organization that has provided outpatient mental health services in Carroll County since 1972. CCYSB has grown into an agency that commits itself to providing a full continuum of mental health and substance use services for children, families, and adults in Carroll County.
The Compliance and Quality Assurance Officer are responsible for compliance and quality/performance improvement programs. The position is responsible for ensuring that the agency complies with all applicable state and federal regulations as well as guidelines established by Commission on Accreditation of Rehabilitation Facilities (CARF). Additionally, the position is responsible for leading an effective performance measurement and management program. The Audit and Compliance Specialist reports to this position.
Essential Functions:
A. Compliance Functions
· Facilitates, manages, and monitors the agency’s compliance with regulatory/licensure/accreditation requirements and standards.
· Keeps abreast of evolving regulatory and accreditation requirements and standards; educates administration and staff regarding any changes; and makes recommendations on how to comply with those changes.
· Provides interpretation and guidance on federal and state regulations as well as accreditation standards.
· Serves as the agency representative to coordinate inspections and surveys.
· Facilitates the development of quality improvement plans (QIPS)/ corrective action plans in response to inspection and survey findings and assures timely submission to the appropriate regulatory/accrediting body.
· Establishes a culture of and processes that support ongoing survey readiness.
· Reviews and creates policies and procedures to assure alignment with regulations and standards.
· Collaborate with IT contractor and Admin Team to develop, implement, and review at least annually a Corporate Compliance Workplan.
· Assures compliance with the policy and procedures for protecting confidentiality and responding to legal demands/requests for records (including clinical records), materials, or persons and court appearances.
B. Quality/Performance Improvement Functions
· Collaborates with administration to develop, implement and evaluate a performance measurement, management and analysis plan that aligns with the agency’s mission, vision, values, and strategic priorities.
· Serves as chair of the Quality Assurance Committee including: Sets agenda, tracks attendance, publishes and distributes minutes.
· Guides administration in the selection and prioritization of performance metrics/indicators that measure efficiency, effectiveness, accessibility, experiences of persons served and other stakeholders, and priority business functions.
· Assures data collection methodology for priority indicators is valid, reliable, accurate, timely and complete. Establishes a target for each indicator based on benchmarks or historical performance. Create a dashboard to track performance against established targets.
· Designs a reporting structure, processes and tools to assure that performance improvement data, information and results are collected, aggregated, analyzed and shared in a consistent and timely manner throughout the organization.
· Identifies opportunities for improvement and assists in developing actions to improve results. Evaluates actions for effectiveness.
· Identifies areas where performance exceeds expectations and facilitates agency celebrations of success.
· Maintains ongoing communication with peers to review programs, provide feedback, discuss new developments, and exchange information.
· Develops and implements training programs for internal and external stakeholders to share performance improvement information that is relevant and accurate. Considers stakeholder feedback.
· Provides quarterly aggregate data for a variety of grant funded programs.
· Provides annual aggregate data for a variety of external reports.
C. Health & Safety Functions
· Collaborates with the facility manager to maintain a healthy, safe, and clean environment that supports quality services and minimizes risk of harm to persons served, personnel and other stakeholders.
· Chairs the Health & Safety Committee by developing/revising the charter, setting the agenda, distributing the minutes and evaluating performance
· In collaboration with the H&S Committee, Finance, the Administrative Team and other stakeholders complete an annual risk assessment and develops a risk management plan with an annual review.
· Assures that critical incident data, including complaints, is aggregated, analyzed, and reported to the Quality Assurance Committee on a routine basis. The report includes but is not limited to causes, trends, improvement actions and reduction strategies.
· Use critical incident data to promote organizational learning.
· Assure external reporting requirements for critical incidents are met.
D. Committee Membership
· Serves on the following committees: Quality Assurance, Leadership, CBH Outcome Group, CARF Planning, Health & Safety.
· Meets committee charter expectations for attendance and participation.
· Complete all committee assignments in a timely manner.
E. Supervisory Responsibilities
· Provides leadership and direction to assist the Audit and Compliance Specialist in performing assigned duties.
· Promotes personal growth and identifies opportunities to enhance supervisee’s knowledge base and skill set.
· Carries out supervisory functions as follows: Interview and selection of new hires,
development and maintenance of job description, ongoing evaluation and performance feedback, orientation and training, coaching and supporting, annual performance evaluation, recommendation for compensation.
Knowledge and Skills Required
· Bachelor’s degree in nursing or master’s degree in social work or psychology with current State of Maryland licensure
· Skilled in the use of performance improvement methodologies and tools
· A minimum of 5 years’ applicable experience
· Certification as a Professional in Healthcare Quality is recommended
· Ability to operate computer programs such as Office 365, Email and Internet
· Ability to use general office equipment (computer, phones, copiers, fax, etc.)
· Ability to use initiative and judgment in scope of designated responsibilities to ensure that matters requiring attention are appropriately delegated or handled
· Able to effectively communicate with clients, supervisors, co-workers, vendors, contractors, and other people in writing and by telephone while remaining professional, pleasant and respectful
· Ability to conduct oneself as a team member through use of collegial words and actions that support co-workers and Carroll County Youth Service Bureau’s philosophy, mission and vision.
Physical Working Conditions
· This job requires sitting for 80% of the workday; lifting/carrying/moving objects up to 10 pounds; bending or reaching to file and working while standing/moving
· Smoke-free office and property
· Lighted, heated/cooled area typical of an office
· Noise from office equipment including telephone, computer, copier, etc. and from staff interactions.
Licensing
· Current licensure as an RN, LCSW-C, or LCPC
Training
· Must participate and successfully complete a variety of training which may include Infection Control, HIPAA, Corporate Compliance/Ethics, Consumer Rights, First Aid/CPR and other training as requested.
Other Requirements
- Valid driver’s license with no more than two points and able to use safe and reliable personal automobiles to transport self and clients.
- Candidates must pass a background check.
Off Site
- When working off-site employees may encounter homes and buildings in the community that may be smoke-filled and non-handicap accessible. Lighting, heating/cooling may vary greatly.
- Ability to work flexible hours, including evenings and weekends.
- Ability to travel between various locations to assist families with reaching their goals.
Note
The information contained herein is not intended to be an all-inclusive list of the duties and responsibilities of the job, nor are they intended to be an all-inclusive list of the skills and abilities required to do the job. Management may, at its discretion, assign or reassign duties and responsibilities to this job at any time.
EEOC
CCYSB is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.
Pay: $95,000.00 - $102,000.00 per year
Benefits:
- 403(b)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
