Senior Quality and Compliance Manager

For over 60 years, HopeLink Behavioral Health (formerly PRS) has been a beacon of support for individuals and families facing behavioral health challenges and life crises. We envision a world where hope is accessible to all. Through high-quality mental health services, crisis intervention, and suicide prevention, we foster an inclusive community where everyone can achieve well-being and a sense of belonging.

Position Summary:

This position has two core job functions Quality Improvement and Compliance This individual will ensure all agency work aligns with regulatory bodies for the organization such as Department of Behavioral Health and Developmental Services (DBHDS) Offices of Licensing and Human Rights as well as the Centers for Medicare/Medicaid and all insurance companies with which HopeLink is credentialed, oversee CARF accreditation standards are met along with identifying, developing, and implementing of training solutions that support the organization's ability to provide quality care in an efficient and effective manner and that meet all licensing and accreditation requirements. This position works closely with the Chief Clinical Officer. The Quality and Compliance Officer serves as a member of Leadership Team.

In this full-time role, you will:

• Creates, implements and monitors the Quality Assurance (QA) and Quality Improvement (QI) Plan across all programs and business units ensuring a continuous cycle of quality management and ongoing feedback loops with key stakeholders with a strong focus on clinical work.
• Conduct annual surveys to clients, monitors supervision notes are completed according to policies.
• Collects, monitors and reports to COO, CEO and Board clinical success measures and program outcomes.
• Provides functional support and consultation for new and current clinical programs to develop quality management objectives, measures, and reporting methods to meet contractual and service quality requirements.
• Actively monitors state and local regulations, state licensing requirements, accrediting body standards, industry best practices, and evidence-based practices to ensure that the organization maintains policies, procedures, processes, and systems that meet and exceed standards and expectations.
• Oversees the completion of in person scheduled and randomized (in person or electronic) audits to ensure all HopeLink facilities and clinical documentation meet the requirements of the regulatory bodies (e.g., DBHDS licensing, CARF), and Medicaid, Medicare and insurance companies' requirements.
• Creates and implements an Annual Risk Management Plan to assess and mitigate clinical/programming risks as much as possible. Reassess plan and update, if needed, annually.
• Reviews and signs off on all critical incident reports, reports to DBHDS when appropriate, conducts root cause analysis for all non-level one critical incidents; completes annual critical incident summary and analysis report for submission to the Board of Directors.
• Provides clinical consultation on critical incident reporting and training to clinical staff.
• Conducts ongoing risk analysis activities, maintains the organization's Risk Management Plan, including reviewing and updating the plan, as needed, at least annually.
• Maintains the organization's Accessibility Plan to include collaborating with program directors and other HopeLink leadership to identify and address identified barriers on an ongoing basis; review and update the Accessibility Plan, as needed, at least annually.
• Develops and ensures implementation of a follow-up process for performance improvements/corrective actions identified from critical internal and/or external analyses, reviews, or audits.
• Ensures the regular analysis and trending of information gathered through QA and QI initiatives.
• Prepares written reports of audit results for various audiences, including the organization's Executive Team.
• Participates as a member of the organization's Health & Safety Committee and Clinical Team.
• Serves as the organization's designated Corporate Compliance Officer; conducts ongoing corporate compliance training; conducts corporate compliance investigations and resulting reports.
• Effectively collaborate with key internal and external partners to develop, implement, and monitor role-specific training plans for all HopeLink staff to ensure compliance with federal, state, local, accrediting body, and organizational goals and standards.
• Identifies external t