Position Overview

The Quality & Compliance Manager is responsible for leading People Encouraging People's quality improvement, compliance, accreditation, risk management, and performance measurement functions. This position partners with leadership to promote continuous quality improvement, ensure compliance with regulatory, contractual, and accreditation standards, and support organizational excellence through data analysis, performance monitoring, quality planning, and risk management.

The Quality & Compliance Manager provides leadership for the Agency's quality governance structure by overseeing quality improvement initiatives, chairing designated quality committees, coordinating organizational quality and compliance plans, monitoring client satisfaction and performance outcomes, and conducting quality audits to ensure compliance with clinical, operational, and documentation standards. Through collaboration with leadership and staff, this position fosters a culture of accountability, continuous improvement, and exceptional service delivery.

Reporting Structure

There are no staff persons reporting to this position. This role provides functional leadership to program directors, clinical leaders, and designated quality champions regarding organizational quality improvement and compliance initiatives.

Specific Responsibilities
• Serve as the Agency's Corporate Compliance Officer and Privacy and Security Officer, overseeing the organization's Corporate Compliance Program and ensuring compliance with HIPAA, the protection of Protected Health Information (PHI), and applicable federal and state privacy and security requirements.
• Lead the Agency's Continuous Quality Improvement (CQI) program and promote a culture of quality, accountability, and organizational excellence.
• Coordinate and maintain compliance with applicable federal, state, contractual, payer, and accreditation requirements, including CARF standards.
• Develop, implement, monitor, and evaluate the Agency's Quality Enhancement Plan, Performance Improvement Plan, Risk Management Plan, Corporate Compliance Plan, and other quality initiatives.
• Develop, monitor, analyze, and report organizational quality indicators, performance measures, and outcome data to executive leadership and committees.
• Prepare and maintain quality dashboards, scorecards, and performance reports to support organizational decision-making.
• Chair and facilitate quality-related committees, including the Incident Insight and Improvement Committee, Quality Enhancement Committee, Consumer Advisory Board, and other committees as assigned.
• Coordinate the Agency's incident reporting and review process, monitor trends, facilitate root cause analyses as appropriate, and oversee corrective action plans.
• Develop, administer, analyze, and report client, family, referral source, and stakeholder satisfaction surveys, using findings to drive quality improvement initiatives.
• Conduct routine quality assurance audits of clinical documentation, including Welligent electronic health records, assessments, treatment plans, progress notes, discharge documentation, medication administration records (MARs), medication documentation, and other clinical and administrative records.
• Monitor documentation quality and compliance with Agency policies, payer requirements, regulatory standards, and accreditation expectations, providing timely feedback and recommendations for improvement.
• Collaborate with program leadership to develop, implement, and monitor corrective action plans resulting from audits, quality reviews, incident analyses, accreditation findings, and regulatory reviews.
• Coordinate organizational readiness for accreditation surveys, licensing reviews, and external audits, including maintaining documentation, evidence, and compliance activities.
• Monitor key performance indicators and quality outcomes across all Agency programs and recommend strategies to improve service delivery and organizational effectiveness.
• Provide consultation, education, coaching, and technical assistance to leadership and staff regarding quality improvement, documentation standards, compliance requirements, accreditation standards, and best practices.
• Lead the Agency's policy management program by developing, reviewing, revising, and maintaining organizational policies, procedures, and protocols to ensure compliance with federal, state, payer, contractual, and accreditation requirements while supporting best

practices and operational excellence. Coordinate the periodic policy review process with leadership and subject matter experts to ensure policies remain current, effective, and aligned with regulatory requirements, accreditation standards, and organizational goals, recommending revisions as needed.
• Collaborate with leadership in identifying organizational risks and implementing strategies to mitigate risk and improve operational performance.
• Provide quality oversight of the medical components of services by monitoring compliance with clinical documentation standards, medication management practices, coordination of care, and applicable regulatory and contractual requirements.
• Review medication records, medication administration documentation, physician and psychiatric provider documentation, nursing documentation, and other medical records to ensure compliance with Agency policies, Maryland Behavioral Health Administration requirements, payer standards, and accreditation expectations.
• Collaborate with medical, nursing, clinical, and program leadership to identify opportunities for improving the quality, safety, and effectiveness of integrated behavioral healthcare services.
• Perform other duties as assigned by the President and Chief Executive Officer.

Principle Accountabilities
• Provide leadership and oversight of the Agency's Continuous Quality Improvement (CQI) program to promote a culture of quality, accountability, and organizational excellence.
• Ensure organizational compliance with applicable federal, state, contractual, payer, licensing, and accreditation requirements, including CARF standards.
• Lead the development, implementation, monitoring, and evaluation of the Agency's quality, compliance, performance improvement, and risk management programs and related organizational plans.
• Monitor, analyze, and communicate organizational quality, performance, risk, and outcome data to support executive decision-making and continuous improvement.
• Oversee the Agency's quality assurance activities, including documentation audits, incident management, corrective action planning, client satisfaction measurement, and quality improvement initiatives.
• Direct the Agency's policy management process to ensure policies and procedures remain current, compliant, evidence-based, and aligned with organizational goals.
• Promote clinical quality and regulatory compliance by overseeing documentation standards, medical quality activities, and collaboration with clinical and medical leadership.
• Maintain organizational readiness for accreditation surveys, licensing reviews, regulatory audits, and other external evaluations while fostering continuous organizational improvement.

Education, Work Experience, and Job Requirements

Education
• Master's degree in Healthcare Administration, Public Health, Business Administration, Social Work, or a related field preferred.
• Certification in healthcare quality, compliance, risk management, or performance improvement (e.g., CPHQ, CHC, or equivalent) preferred.

Work Experience
• Minimum of three (3) years of progressively responsible experience in quality improvement, compliance, accreditation, risk management, or performance improvement within a behavioral healthcare, healthcare, or human services organization required.
• Experience with CARF accreditation standards, regulatory compliance, quality management systems, and performance improvement methodologies preferred.
• Experience conducting clinical documentation reviews, quality audits, incident management, root cause analysis, and corrective action planning preferred.
• Experience developing organizational policies, procedures, quality plans, and performance reports.
• Experience facilitating committees, leading cross-functional teams, and providing staff education and consultation.
• Experience working with electronic health record (EHR) systems, preferably Welligent or a comparable behavioral health EHR.

Knowledge, Skills, and Abilities
• Thorough knowledge of behavioral health regulations, accreditation standards, quality improvement principles, and risk management practices.
• Knowledge of Maryland Behavioral Health Administration (BHA), Medicaid, and payer requirements preferred.
• Strong analytical, organizational, problem-solving, and critical thinking skills.
• Ability to analyze and interpret data, identify trends, and make recommendations that improve organizational performance.
• Strong project management skills with the ability to prioritize multiple initiatives and meet deadlines.
• Excellent written, verbal, interpersonal, and presentation skills.
• Proficiency with Microsoft Office Suite, including advanced Microsoft Excel, Word, and PowerPoint.
• Ability to prepare reports, dashboards, scorecards, and presentations for executive leadership and governing bodies.
• Ability to maintain confidentiality and exercise sound judgment when handling sensitive information.
• Ability to work independently while building collaborative relationships across all levels of the organization.
• Commitment to continuous quality improvement, organizational excellence, and person-centered behavioral healthcare.

Physical Requirements
• Ability to sit, stand, walk, and use standard office equipment for extended periods.
• Ability to travel to Agency locations and attend meetings, trainings, and accreditation activities as required.