JOB SUMMARY:

The Director of Quality and Compliance will promote and hold the organization to high ethical standards and adherence to regulatory matters. Manage, develop, coordinate and support system improvement to promote the highest level of compliance and quality. Will oversee cross-functional teams responsible for regulatory and contractual compliance through conducting regular internal audits to mitigate enterprise and programmatic risks associated with service delivery and day to day operations while actively driving continuous improvement. Areas of compliance include, but are not limited to: regulatory and contractual obligations, workplace safety, mandatory staff training requirements, HIPAA and 42 CFR Part 2 (confidentiality of substance use disorder treatment records), data privacy laws, DHS licensing standards, accreditation agency requirements, and board governance.

AUTHORITY:

Has the authority to issue corrective actions after consultation with and approval from the COO and/or HR Director.
Note: Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory; overtime, shift work, work during a holiday, a rotating work schedule, a changed work schedule or a work schedule other than Monday through Friday.
Note: This job description is not intended to be an inclusive list of responsibilities, but a guide to basic areas of responsibility. Other tasks may be assigned from time to time by the supervisor and should be considered a part of this job description. All job descriptions are subject to periodic review. Any changes in job descriptions will be addressed to both the employee and supervisor.

SKILLS AND QUALIFICATIONS:

• Capable of performing the essential functions of the job, with or without reasonable accommodation.
• Ability to understand and communicate written and verbal directions, including transmitting and maintaining confidentiality of sensitive information in a manner focused on improvement and moving forward.
• Regular attendance, reliability and punctuality is necessary to meet the needs of the business.
• Well organized with excellent attention to detail and analytical and problem-solving skills
• Ability to work collaboratively with various departments to manage tasks and projects that span multiple departments to reach common goals and objectives.
• Strong interpersonal and communication skills, with the ability to navigate and manage relationships in a multi-departmental environment.
• Aptitude to work independently with excellent time management skills.
• Skilled at establishing and cultivating strong relationships.
• Ability to take initiative and strengthen relationships with current and new communities.
• Experience in using technology to enhance compliance processes and reporting.
• Experience in conducting audits including summarizing findings, making recommendations, and developing continuous improvement activities.
• Experience in leading and conducting investigations on compliance-related matters, maintaining confidentiality.
• Experience interpreting and applying regulatory statues, contracts, provider licensing requirements, and technical advisories.
• Ability to author enterprise-level policies, procedures, and management reports.
• Experience in the following areas is preferred: data privacy, HIPAA, 42 CFR Part 2 (confidentiality of substance use disorder treatment records), Minnesota Statute 245G, OSHA regulations, and CARF accreditation standards.
• Must be able to pass DHS Rule 11 background check.
• Current two step Mantoux/Tuberculosis Skin Test, TB Gold test, or ability to obtain.
• Valid state driver’s license and positive driving record (periodic review of driving record required).

EDUCATION AND EXPERIENCE

• 4-yr. degree in CD Counseling or related field, or equivalent training and experience preferred. (Master’s degree preferred)
• CD license in the state of MN (ADC-T or LADC).
• Licensed as a Mental Health Professional in the State of MN (preferred)
• 2+ years of related experience in compliance & quality control, risk management or regulatory compliance (preferred).
• Proficiency in Microsoft Office Suite

• Lead the development, implementation, and oversight of the organization’s compliance program, including scheduling and conducting audits and risk assessments, issuing corrective actions, and recommending process improvements.
• Lead and coordinate all activities related to regulatory audits and compliance, including preparation, facilitation, and follow-up. This includes oversight of audits from agencies such as MN DHS Licensing, compliance with MN Statute 245G, CARF accreditation, and other applicable regulatory bodies
• Work with other leaders to develop and implement training programs and staff development in coordination with the Chief Operating Officer and HR Director.
• Participate in the creation, execution and maintenance of strategic goals and initiatives for the agency.
• Investigate and/or coordinate investigations conducted internally by others regarding service complaints, significant incidents, privacy and whistleblower incidents, potential fraud, and others as needed ensuring all regulatory procedures and timelines are followed.
• Coordinates all external regulatory inquiries or corrective actions timely with all departments, programs, government agencies, and contractors.
• Research, develop, implement and oversee programming and clinical policies, practices and procedures, as required.
• Recommend policies and programs to the Chief Operating Officer that encourage program compliance, operating efficiency and the accomplishment of organizational objectives.
• Ensure program functions and facilities in compliance with all pertinent local, state and federal laws and applicable licensing requirements and standards.
• Regularly review and make proposed revisions of policies and procedures to the Chief Operating Officer, or delegate.
• Develop and maintain good working relationship with all Progress Valley ancillary programs/services.
• Ensure self-development by attending seminars, conferences, etc., to keep apprised of new methods and procedures. Remain current on quality and compliance regulations pertaining to position.
• Conduct regularly scheduled client chart reviews/audits and ensure all files (open & closed) have all necessary and required documentation.
• Attain, maintain and promote a positive, safe, harmonious, productive and challenging work environment.
• Maintain favorable driving record (favorable is left to the interpretation of the employer and any agent acting on behalf of the employer.)
• Provide other services as needed to attain all program outcomes desired.
• Perform other tasks/duties as assigned by supervisor or management.