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Catholic Charities, Archdiocese of New York

Director of Compliance

Regulatory Compliance & EthicsConfirmed live in the last 24 hours
Full-timeBronx, NY, USA$115k - $120k /yr

About the Job

Requirements

  • Seven years of experience working in compliance.

Responsibilities

  • Lead the Quality Improvement Department and supervise the Quality Improvement Manager.
  • 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.
  • Manage BOH’s electronic health record by serving as an internal Help Desk for staff and communicating with the vendor to troubleshoot issues and plan for changes.
  • Oversee BOH’s participation in Regional Health Information Organizations, provide training to staff around such, and ensure all required documentation is available and current.
  • Populate and analyze data for the quarterly BOH Divisional Board Report.
  • Develop, implement, and analyze Consumer Satisfaction Surveys and Program Evaluation Studies.
  • Monitor the provision of services to identify operational improvements and recommend plans for such.
  • Create new forms for implementation consistent with operational needs and requirements.
  • Prepare and update policies and procedures consistent with regulatory requirements.
  • Receive and track client concerns and grievances, investigate when indicated, recommend a course of action, provide a response, and prepare related reports.
  • Maintain communication with the New York State Office of Mental Health, The Justice Center, and/or NIMRS/WSIR regarding all reportable incidents.
  • Prepare the Incident Review Committee agenda and tracking and trending reports for internal incidents, facilitate the committee meeting, and write the minutes.
  • Conduct special investigations under the direction of BOH leadership and/or in coordination with The Justice Center.
  • Audit client case records, prepare findings reports, conduct findings review meetings, and provide follow-up training to staff as needed.
  • Audit documentation for Medicaid billing submission, prepare related reports, and resolve client issues impacting billing; coordinate with the Finance Department as needed.
  • Train staff in compliance with audit requirements, conduct environmental assessments, coordinate peer audit reviews, and perform mock licensing and monitoring audits.
  • Participate in licensing audits and monitoring reviews and assist in preparing Corrective Action Plans as needed.
  • Maintain and update HIPAA policies and procedures to ensure consistency with applicable requirements.
  • Investigate HIPAA and compliance-related concerns, make required notifications, and prepare reports.
  • Manage requests for Protected Health Information and prepare responses.
  • Monitor and evaluate Corporate Compliance risk areas and develop mitigation plans.
  • Annually draft and update the Compliance Work Plan, including training, monitoring, auditing, and responding to compliance issues.
  • Update policies and procedures designed to ensure Corporate Compliance.
  • Participate in training Board members, staff, and contractors regarding Corporate Compliance.
  • Respond to Corporate Compliance concerns and conduct investigations as directed by agency leadership.
  • Prepare Corporate Compliance quarterly reports, facilitate bi-annual Compliance meetings, and write meeting minutes for the Divisional and CCCS Board Meetings.
  • Build and maintain a comprehensive understanding of laws and regulations for property management.
  • Review and report on the status of lease-related documentation to ensure it is current.
  • Review and track housing inspection documentation, including photographs, to promote safe environments and accountability in apartment programs.
  • Conduct scheduled and unscheduled program visits, including community-based apartments, and prepare reports summarizing visits.
  • Prepare reports on clients’ benefits and entitlements to identify residents in need of additional support.
  • Participate in the non-payment and/or holdover eviction process to ensure compliance with internal policies and procedures and legal requirements.
  • Track the status of outstanding property management-related activities to provide checks and balances on apartment repair issues.
  • Develop an annual staff training schedule in consultation with BOH leadership.
  • Work with BOH leadership to secure consultants for training and provide support as needed.
  • Facilitate ongoing employee training at times consistent with program and staff needs.
  • Adhere to personnel and residential policies and procedures outlined in the CCCS Personnel Policies and Procedures Manual and BOH Policies and Procedures Manual.
  • Perform other duties consistent with the department’s and its programs’ goals and objectives, as assigned by Beacon of Hope Administrators.
  • Travel to sites throughout New York City at least 5% of the time.
  • 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, use a computer, and sit in meetings at least 75% of the time.
  • Walk sites to inspect the environment, stand in place, and bend and lift small items 20% of the time.
  • Management positions must be available by cell phone 24 hours daily; the usual work schedule is 9:00 AM–5:00 PM.

Desired Qualifications

  • A master’s degree in a mental health discipline is preferred.
  • Five years of experience working in and/or with a government-contracted program is preferred.
  • Five years of experience working with a special needs population is preferred.

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