Director of Compliance

Job Title: Director of Compliance

Location: Bronx

FLSA Status: Full Time, Exempt

Classification: Professional

Department: Beacon of Hope

Reports to: Division Director

Supervisory Responsibilities: Yes X No _

Summary:

The Director of Compliance works with Beacon of Hope (BOH) staff to ensure programs remain in compliance with applicable regulatory standards set forth by the New York State Office of Mental Health (OMH) and provides supervision to the Quality Improvement Manager. Major areas of responsibility include serving as a liaison with external regulatory entities, assessing the quality of program services, facilitating staff development, ensuring HIPAA and Corporate Compliance, and performing Administrative and/or program related duties as directed.

Essential Duties and Responsibilities include the following:

Department And Systems Management:

1. Lead the Quality Improvement Department and supervisee the Quality Improvement Manager.
2. Serve as BOH’s representative and gatekeeper for regulatory entities and external provider support systems to fulfill compliance requirements, support care coordination, submit reports and maintain operations.
3. Manage BOH’s electronic health record record by serving as an internal Help Desk for staff and communicating with the vendor to troubleshoot issues and plan for changes.
4. Oversee BOH’s participation in Regional Health Information Organizations, provide training to staff around such, and ensure all required documentation is available and current.
5. Populate and analyze data for the quarterly BOH Divisional Board Report
6. Develop, implement and analyze Consumer Satisfaction Surveys and Program Evaluation Studies.
7. Monitor the provision of services to Identify operational improvements and recommend plans for such.
8. Create new forms for implementation consistent with operational needs and requirements.
9. Prepare and update policies and procedures consistent with regulatory requirements.

Concerns And Incidents:

1. Client Concerns and Grievances: Receive and track client concerns and grievances, investigate when indicated, recommend a course of action, provide a response, and prepare related reports.
2. Incident Management: Maintain communication with the New York State Office of Mental Health, The Justice Center, and/or NIMRS/WSIR regarding all reportable incidents.
3. Incident Review Committee: Prepare the agenda, as well as tracking and trending reports for internal incidents. Facilitate the committee meeting and write-up the minutes.
4. Special Investigations: Conduct investigations under the direction of BOH leadership and/or in coordination with The Justice Center.

Operations And Audit:

1. Utilization Reviews: Audit client case records, prepare findings reports, conduct findings review meetings, and provide follow-up training to staff as needed.
2. Medicaid Billing: Audit documentation for submission, prepare related reports and resolve client issues impacting billing. Work in coordination with the Finance Department around such, as needed.
3. Audit Preparation: Train staff on compliance with audit requirements, conduct environmental assessments, coordinate peer audit reviews, and perform mock licensing and monitoring audits.
4. Audits: Participate in Licensing audits and Monitoring Reviews. Assist in the preparation of Corrective Action Plans as needed.

HIPAA And Corporate Compliance:

1. Maintain and update HIPAA policies and procedures to ensure consistency with requirements for such.
2. Investigate HIPAA & Compliance related concerns, make notifications as required and prepare reports.
3. Manage requests for Protected Health Information and prepare responses.
4. Monitor and evaluate the Corporate Compliance risk areas and develop plans to mitigate such.
5. Annually draft and update the Compliance Work Plan, including training, monitoring, auditing,, and responding to compliance issues.
6. Update policies and procedures designed to ensure Corporate Compliance.
7. Participate in training of Board members, staff and contractors regarding Corporate Compliance.
8. Respond to concerns regarding Corporate Compliance and investigate as directed by agency leadership.
9. Prepare the Corporate Compliance quarterly reports, facilitate the bi-annual Compliance meetings, and write-up meeting minutes for the Divisional and CCCS Board Meetings.

Property Management:

1. Builds and maintains a comprehensive understanding of laws and regulations for property management.
2. Reviews and reports on the status of all lease related documentation to ensure such is current.
3. Reviews and tracks housing inspection documentation including photographs to promote safe environments and accountability in apartment programs.
4. Engages in scheduled and unscheduled program visits, including community based apartments, and prepares reports summarizing visits.
5. Prepares reports on clients’ benefits and entitlements to identify residents in need of additional support.
6. Participates in the non-payment and/or holdover eviction process to ensure compliance with internal policies and procedures as well as legal requirements for such.
7. Tracks the status of outstanding property management related activities to provide checks and balances on apartment repair issues.

Training:

1. Develop an annual staff training schedule in consultation with BOH leadership.
2. Works with BOH leadership to secure consultants for training and provide support as needed.
3. Facilitates ongoing employee training during times that are consistent with program and staff needs.

General:

1. Adhere to personnel and residential policies and procedures as outlined in the CCCS Personnel Policies and Procedures Manual and BOH Policies and Procedures Manual.
2. Perform other duties, consistent with the goals and objectives of the department and its programs, as assigned by Beacon of Hope Administrators.

Position Type and Expected Hours of Work:

This is a full-time position. Generally, works 9:00 AM – 5:00 PM. Management positions must be available 24 hours daily by cell phone.

Working conditions and physical demands:

The demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• Travel to sites throughout New York City to at least 5% of the time using transportation, traversing streets, ascending/descending stairs, and exposed to outside weather conditions.
• Traverse neighborhoods that may require a high level of alertness and awareness of surroundings.
• Assess and work in varied environmental conditions.
• Work with clients who require consistent and comprehensive support.
• Remain stationary at a workstation and use a computer and sit in meetings at least 75% of the time.
• Walk site (s) to inspect environment, stand in place, and bend and lift small items, 20% of the time.

Qualifications:

Education and/or experience:

1. Master’s degree in a mental health discipline is preferred.
2. Seven years of experience working in the area of compliance
3. Five years of experience working in and/or with a government contracted program preferred.
4. Five years of experience working with a special needs population preferred.

Skills, Licenses, and/or competencies:

• Excellent judgment
• Excellent assessment skills
• Excellent oral and written communication skills
• Excellent organizational, time management and planning skills
• Excellent knowledge of social service delivery systems and local resources
• Ability to work flexibly
• Ability to problem solve
• Ability to think critically
• Ability to work proactively
• Ability to think strategically
• Ability to work independently
• Ability to prioritize effectively
• Ability to teach and train others
• Ability to demonstrate quick learning skills
• Ability to demonstrate a strong work ethic
• Ability to maintain professional boundaries
• Ability to manage and minimize agency risk
• Ability to successfully pass “prove-it” skills test
• Ability to communicate professionally with others
• Ability to demonstrate a good knowledge of accounting
• Ability to demonstrate flexibility, creativity, and initiative
• Ability to appropriately assess and respond to systems issues
• Ability to handle multiple tasks and shift between responsibilities
• Ability to demonstrate effective adaptation to computer applications
• Ability to work effectively with others and demonstrate conflict resolution skills
• Ability to use multiple databases simultaneously to record and track information
• Ability to demonstrate effective organizational, time management and planning skills