Director of Quality and Compliance - Miami County

Due to continued growth and expansion within 4C Health, we are adding a senior leadership position of Director of Quality and Compliance.  This is a new position, not a replacement.  Come make a difference with us, working one on one with our clients! 4C Health is a growing non-profit, comprehensive Community Mental Health Center serving the communities of North Central Indiana for over 45 years. We are rural behavioral health specialists integrated in the physical and behavioral health well-being for our staff and consumers. Our crisis continuum of care includes Mobile Crisis Teams, a Crisis Stabilization Unit, and an Acute Care Unit. 4C Health continues to grow, and we are looking for agile staff committed to caring for our consumers, communities, and each other! Our workforce is the heartbeat, meeting the needs of our local communities, don’t wait, join our team!

POSITION SUMMARY:

This position is responsible for overseeing the Quality Improvement and Records Management. Has a clear understanding of state and federal requirements including a clear understanding of Medicaid regulations. Ensuring that the agency is prepared for all internal audits and external audits. Ensuring that the agency is in compliance with all state and federal regulations.  Ensuring accreditation compliance with Joint Commission, DMHA, etc. Ensuring the medical record is in compliance with all state and federal regulations and laws.  Ensuring the compliance of Infection Control with state, federal and accrediting bodies. W. Provide direct supervision to quality/compliance associates.

This position operates with a degree of autonomy and must exercise tact, judgment and confidentiality in contact with the public, governmental bodies, other agencies, clients and families, as well as fellow associates of the Center. Work is very broad in scope and requires a high level of professionalism.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Assist in the development of annual work audit plans. 
• Responsible for department timely monthly completion and review of all internal quality audits.
• Prepare for and oversee external reviews and audits.
• Continually evaluate data collection methods to ensure all relevant information is fully and accurately collected for various Quality Improvement work plan metrics.
• Oversee client satisfaction survey, preparing reports and providing feedback to the Chief Compliance and Quality Officer.
• Lead site visit preparation for various regulatory and accreditation agencies.
• Monitor and track all state and federal quality improvement and reporting requirements including but not limited to Division of Mental Health & Addiction, Joint Commission, Indiana State Department of Health, Center for Medicare Services.
• Compile data relative to client complaints monthly.
• Ensure compliance with DMHA relative to certification of CCBHC, CMHC, IPU, Transitional Living and Supervised Group Living.
• Ensure Plans of Correction are completed, uploaded and updates provided as required.
• Oversees the management of agency Policy & Procedures and ensures adherence to the policy on Policy & Procedure.
• Ensure all department and staff supervised have daily, weekly, and monthly key performance metrics and that supervision occurs in line with metric performance.
•  Ensures the maintenance and destruction medical records that meet state and federal standards for maintenance and destruction, log information according to established procedures.
•  Understands process for submission of assessments, NOMS, SDOH, etc. to DARMHA and how the error reports work and are managed. 
• Oversight of Infection Control Program:
  • Ensure that the infectious waste/handling and disposal policy is being followed.
  • Ensure the maintenance of up-to-date records of annual health screening and immunization records (including Covid) for all associates, providing information relating to non-compliance as we