Senior Director of Compliance

Senior Director of Compliance (Sepulveda Quality Assurance)

This position is partially remote, and you have the option to elect into a 9/80 flex work schedule. The pay range for this position is between $144,440 - $160,490 annually. 

About Didi Hirsch 

Didi Hirsch Mental Health Services has been a national leader in whole-person mental health, crisis care, and substance use services since 1942 and is home to the nation’s first Suicide Prevention Center. We are a nonprofit organization providing care to nearly 200,000 people annually across our programs. Didi Hirsch has deep roots in community-based mental health and a commitment to providing culturally responsive services that are just and equitable.  

As an organization, we value equity, diversity, and inclusion. More than 1,000 dedicated employees and volunteers make Didi Hirsch’s work possible. We intentionally recruit and retain a workforce that is reflective of the communities we serve and strive to cultivate a sense of belonging for them. We embrace employees and candidates from all backgrounds who want to help make this vision a reality.  

Summary

This role provides leadership and support in the development and maintenance of clinical compliance and clinical risk management activities for the agency. Responsible for overseeing and ensuring adherence to all local, State, Federal, and regulatory requirements, standards, and policies governing the services provided by the Agency. This role plays a crucial role in maintaining ethical standards, legal compliance, and accreditation status and ensuring utilization of best practices and care throughout the agency. 

Primary Duties

• Assists VP of Health and Innovation in the developing, implementing, and managing the Agency’s clinical compliance program which includes but is not limited to safeguarding client rights, ensuring client privacy, preventing fraud and abuse, addressing client grievances, HIPAA violations, and incident reporting.
• Leads or Co-leads compliance and clinical risk management committees and related activities.
• Collaborates with QI Division Director to establish internal compliance policies, determines relevant metrics, oversees internal audits to determine potential risks and areas of improvement agency wide.
• Interacts with all levels of management, employees, clients, external regulators, and legal counsel to address compliance related issues.
• Conducts compliance/privacy investigations, provides consultation to staff, maintains required documentation, tracks metrics, and develops, and implements policies and procedures.
• Manages incident reporting which includes but is not limited to reviewing critical incident reports, maintaining related policies and procedures, collaborating with stakeholders on conducting root cause analyses, collaborating with program leadership in developing and implementing improvement/corrective action plans, and monitoring ongoing compliance with improvement initiatives. 
• Promotes an effective compliance culture by organizing training related to all regulatory requirements and best practices.
• Responsible for the management and administration of solutions used for managing critical incident reporting.
• Collaborates with QI Division Director on quality assurance and quality improvement activities agency wide.
• Leads all accreditation/certification agency-wide related activities which include but are not limited to initiating accreditation/certification, leading the agency through accreditation/certification and re-accreditation/re-certification activities. This includes accreditations and certifications with regulatory bodies such as Joint Commission Accreditation, Medi-Cal, and Community Care Licensure (CCL), among others.
• Ensures compliance with all accreditation/certification requirements.
• Tracks and maintains policies and procedures related to accreditation/certification.
• Monitors regulatory requirements and changes in the compliance landscape to ensure the Agency remains compliant with relevant requirements.
• Provides oversight of release of records/information according to regulations.
• Oversees all aspects of Health Information Management which includes but is not limited to release of records and health information exchange.
• Acts as the Privacy Officer.
• Oversees the development, maintenance, implementation and adherence of policies and procedures related to but not limited to: Accrediting body requirements, local, State, and federal laws, and regulations. 
• Develop and implement internal policies and procedures related to Critical Incident Reporting, compliance/privacy, complaints and grievances. 
• Responsible for the managemen