Director of Compliance (Part Time)

Job Description

Job Description

Come be an essential and important part of helping people "behind the scenes"! Hope house is looking for a Director of Compliance that can help us navigate the ever changing worlds of compliance and accreditation.

JOB SUMMARY : Under the supervision of the Executive Director, the Director of Compliance provides advanced support to the Executive Director and the organization. This position is crucial in the management of compliance, regulatory bodies, and reporting that impacts the organization.

DIRECTOR OF COMPLIANCE JOB DUTIES:

• Develops and reviews company policies on an annual basis and as needed.
• Regularly audit company procedures, practices, and documents to identify possible risk.
• Responsible for the oversight of the Survey Monkey domain including but not limited to:
• Design or redesign of ARI questionnaires in Survey Monkey as needed to collect valid data
  1. Works with Department Heads on survey monkey analysis of all data on various questionnaires and accurately add the data to the scorecards.
  2. Monitors emergency drills to determine compliance with CARF requirements.
• Collects and analyze AMA and Staff discharge information.
• Collects and accurately enters client success/retention rates on scorecards.
• Assists with the data collection regarding nosocomial and community acquired rates and types (infection control).
• Completes quarterly and annual analysis of grievances.
• Maintains updated Corporate Compliance Plan.
• Serves at the Health and Safety/Risk Officer conducting quarterly meetings to identify areas of risk.
• Collect and analyze debriefings following critical incident reports.
• Determines if an RCA is required and conducts meeting in a timely manner following a critical incident report.
• Pulls quarterly data for the purposes of
  1. CQI meetings
  2. Updating plans and analyses
  3. Pie charts
• Designs, prints and displays quarterly pie charts at each location.
• Completes data on performance measurement indicator scorecards.
• Completes annual performance measurement and management analysis.
• Collects and maintains complaints and grievances including investigation needs and follow up
• Oversight of internal inspection completion to include:
  1. Maintaining annual schedule and assigning individuals to complete
  2. Enters completed inspection information into survey monkey
  3. Creates and assigns action plan
  4. Conducts initial follow up on action plan and communicated incomplete assignments to corresponding supervisor
• Completes applications for State licensing and CARF accreditation in a timely and efficient manner
• Maintains updates to CARF standards and communicates updates and action plans to corresponding personnel.
• Advises management on the company’s compliance with laws and regulations.
• Maintains Executive Committee meeting minutes and facilitates CARF updates/discussion
  1. Prepares corresponding updates to bring to the meeting based on topics scheduled
• Maintains schedule for CQI meeting, prepares information to present, and completes CQI meeting minutes.
• Completes department audits prior to CARF survey or on an as needed basis to ensure compliance to standards (ex. Nursing and HR audit)
• Completes Quality Improvement Plan following receiving the CARF Survey Report.
• Schedules and leads annual meetings to complete assessments for new fiscal year plans and completion of new plans including performance measurement scorecards.

MINIMUM QUALIFICATIONS:

• Bachelor’s Degree; preferably in Healthcare Management
• Previous experience in a compliance capacity
• Knowledge of laws/regulations that impact a healthcare environment
• Preferred previous experience in a non-profit environment
• Strong written and oral communication skills,
• Administrative supervisory experience; and
• Strong computer skills.