Job Summary
Are you a motivated, positive, and service-oriented leader who is passionate about making a difference? If so, we'd love to hear from you.
We are seeking a Compliance and Quality Director to lead our organization's compliance and quality management efforts. In this role, you will ensure compliance with Department of Human Services (DHS) contractual requirements and regulatory standards by developing, implementing, and maintaining systems that measure, monitor, and evaluate the performance of the Behavioral Health Managed Care Organization, its subcontractors, and the Tuscarora Managed Care Alliance.
This position provides leadership and oversight to departmental staff, ensuring objectives are achieved efficiently and effectively through strong supervision, direction, and performance management. The Compliance and Quality Director exercises independent judgment in addressing complex regulatory issues, contractual compliance, and subcontractor relationships while promoting continuous quality improvement throughout the organization.
We're looking for a self-starter who is committed to excellence, values collaboration, and wants to make a meaningful impact in the community. If you're ready to take on a rewarding leadership role, we'd love to connect with you.
Apply today and help us make a difference in the lives of those we serve.
Requirements
Education/training
Bachelor's degree from a four-year college or university in Human Services/Social Services or related field. Computer proficiency required.
Work Experience
Two years of managed care related experience required. Supervisory experience preferred.
Job Description
Franklin County
Compliance and Quality Director
Position Description Exempt
Overall Objective of Job
The Compliance and Quality Director ensures compliance with Department of Human Services (DHS) contractual obligations and regulatory compliance by developing, implementing and maintaining methods and standards that measure and monitor the Behavioral Health Managed Care Organization's other subcontractor's and Tuscarora Managed Care Alliances' performance. The Compliance and Quality Director will be responsible for the supervision, direction of work and management of subordinates ensuring departmental objectives are fulfilled in an efficient, effective manner. The position exercises independent judgement related to complex issues and sub-contractual relationships.
Essential Functions of Job
1. Develop, implement and evaluate on an annual basis TMCA's Quality Management Oversight Program Description and corresponding Work Plan with crosswalk to the DHS Behavioral HealthChoices Agreement Program Standards and Requirements (PSR) to measure adherence to the contractually required elements. The Work Plan scope of activity will address PSR Sections:
a. In-Plan Services
b. Coordination of Care
c. Member Services/Member Rights
d. Complaints and Grievances
e. Provider Network, Provider Enrollment/Credentialing and Re-credentialing
f. Service Access
g. Utilization Management and Quality Management
h. Program Outcomes and Deliverables
2. Additionally, the position is responsible to ensure compliance with PSR Appendices H, I, J, K, L, M, Q, T, AA, BB, and CC.
3. Develop and oversee TMCA's contracted Consumer/Family Satisfaction Team for adherence to DHS and TMCA contractual requirements.
4. The Compliance and Quality Director will ensure the development and maintenance of HealthChoices Program related Policy and Procedure in written format
5. Oversee the BHMCO adherence to DHS Standards on required Performance Improvement Projects (PIPs). Validate BHMCO's PIPs data. Edit for TMCA approve and submit BHMCO's PIPs quarterly reports. The position will serve as primary contact to DHS related to communication and/or problem resolution.
6. Serve as TMCA's primary staff person responsible for the DHS required Program Evaluation Performance Summary (PEPS) Process. The Director of Compliance and Quality will coordinate externally with DHS and TMCA Subcontractors to ensure
compliance to the PEPS process to include identification, coordination and verification of deliverables, coordination of on-site audits , development and monitoring of any Corrective Action Plans related to findings by DHS until resolution of the deficient issue.
7. Develop processes for the review of Member Critical Incidents to ensure the BHMCO reviews, investigates, and takes corrective action (if necessary). Review Critical Incident trends to identify opportunities for system improvement.
8. Analyze BHMCO annual provider and member survey results. Ensure BHMCO's utilizes feedback to implement interventions aimed at improving the quality of the behavioral health systems.
9. Develop a process for oversight of the BHMCO's annual Treatment Record Reviews of Provider records. Monitor outcomes of reviews and ensure BHMCO's follow up with Corrective Actions as necessary.
10. Develop and manage the process of BHMCO's investigation and actions in regard to Provider issues such as treatment quality issues, fraud, abuse, and non-compliance with established regulations and best practice standards. The Quality Manager may also recommend Provider issues to BHMCO for action.
11. Develop and oversee the BHMCO's specific activities related to the coordination and interaction with DHS HealthChoices endeavors to include Physical HealthChoices and Community HealthChoices, Will work the the BHMCO to develop processes for the integration of physical and behavioral health care management plans for HealthChoices members.
12. Responsible for the process design, development, coordination, monitoring and validation of performance of the BHMCO's Performance Objectives.
13. Serve as the representative for Stakeholders on any on any BHMCO or CFST quality management concern.
14. Attend activities and any meetings with state or county entities.
15. Monitor the provider network by attending site visits and provider meetings.
16. Monitor the provider network by attending site visits and provider meetings.
17. Be available to meet with families and members to educate them on the process of accessing services and provide support and assistance when barriers arise.
18. Responsible for subordinate employee assignment of work activities, employee development and evaluation.
19. Participates in strategic planning and development for Tuscarora Managed Care Alliance. Performs work activities to fulfill the goal and objectives of the organization.
20. Serves as TMCA representative on the BHMCO Credentialing Committee.
21. Serves as TMCA's Corporate Compliance Officer. Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations. Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal
22. with similar situations in the future. Ensures proper reporting of violations or potential violations to TMCA's Executive Director. Monitors the performance of the
23. Compliance Program and relates activities on a continuing basis taking appropriate steps to improve its effectiveness
24. Responsible for the process development, coordination and oversight of current and future HealthChoices program reports/deliverables to the Office of Mental Health and Substance Abuse Services that are not financial in nature. This includes but is not limited to People Stat Reporting, BHRS Exception Reporting, RTF Census Reporting, Jail Project Reporting, CFST Reporting and PLE Data Submission.
25. Participates in the contract development with IT vendors.
26. Perform other duties, tasks and special projects as required.
Other Duties of Job
1. Attend meetings, training, in service as required.
2. Performs other job-related duties as required.
Supervision Received
Received occasional instruction from the Director of Managed Care.
Supervision Given
Supervises Compliance and Quality Specialist and all other future positions placed under this position.
Working Conditions
1. Works indoors in crowded workspace, lighting, temperatures, but with fluctuation in ventilation.
2. Works with average indoor exposure to noise and stress, but subject to frequent disruptions.
3. Normal indoor exposure to dirt/dust.
4. Travels occasionally as needed for consumers, meetings and other governmental /managed care business.
Physical and Mental Requirements
1. Must possess the ability to record, convey and present information, explain complex procedures and follow instructions.
2. Must be able to sit for long periods throughout the workday with intermittent periods of standing, walking, bending, twisting, reaching and driving as necessary to carry out duties of job.
3. Dexterity requirements range from simple to coordinated movements of hands and fingers, feet and legs and torso as necessary to carry out duties of the job.
4. Sedentary work with occasional lifting/carrying of objects with a maximum weight of 10 pounds.
5. Must be in good general health and demonstrate emotional stability.
6. Must be able to cope with the physical and mental stress of the position.
7. Must be able to physically and mentally react quickly in the event of a disturbance or physical outbreak.
8. Must be able to pay close attention to details, coordinate tasks efficiently and concentrate on work.
9. The positions work schedule and priorities are subject to unpredictable shifts due to external influences, time frame constraints or self-imposed priority changes.
Qualifications:
A. Education/training
Bachelor's degree from a four-year college or university in Human Services/Social Services or related field. Computer proficiency required.
B. Work Experience
Two years of managed care related experience required. Supervisory experience preferred.
Knowledge, Skills and Abilities Required
1. Must be able to speak and understand the English language in order to carry out essential duties of position.
2. Must possess excellent verbal and written communication skills.
3. Must possess initiative and problem solving skills.
4. Must possess the ability to understand complex regulations and requirements of the department.
5. Must possess the ability to interface effectively with all levels of county management.
6. Must possess a general understanding of fiscal planning, budgeting and balance sheets, etc.
7. Must possess strong analytical skills.
8. Must be accurate and detail oriented.
9. Must possess strong organizational skills.
10. Must possess a working knowledge and understanding of HealthChoices.
11. Must possess a working knowledge and understanding of the medical assistance managed care program.
12. Must possess a working knowledge and understanding of the Franklin/Fulton County's MH/MR and D/A service systems, and the providers in those systems.
13. Must possess a working knowledge and understanding of the fundamental medical assistance regulations, particularly regarding program service categories under the MA fee schedule.
14. Must possess basic to Intermediate skill using a personal computer and various software packages.
15. Must have customer service experience.
16. Must possess the ability to work independently and proceed with objectives.
17. Must possess the ability to work as part of a team.
18. Must possess the ability to maintain confidential information and handle confidential matters with regards to client and staff information/records
19. Must possess the knowledge and ability to practice effective organizational and conflict management techniques.
20. Must possess the advanced interpersonal skills in dealing with consumers, co-workers, agencies and other organizations.
Contact Details
We offer an excellent benefit package including medical, dental, vision, prescription, life insurance, paid time off, tuition reimbursement and a retirement plan!
To apply for this position, please complete our online application.
