Compliance and Outcomes Manager
Compliance and Outcomes Manager
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Salary Not Disclosed
1 Vacancy
Job Description
***Signing Bonus $1500
Sign-On Bonus for Bilingual Applicants: $1500 (Distributed in 3 parts: $500 after 30 days $500 after 6 months and $500 after 12 months of employment)
JOB TITLE: Compliance and Outcomes Manager
LOCATION: Gateway Medical Sobering- Albuquerque New Mexico
Who are we
Horizon Services Inc. (HSI) is a nonprofit established in 1974 that offers addiction treatment with the goal of reducing substance use and mental health related challenges for people from all walks of life including those from some of the most disenfranchised and marginalized communities. We practice our values of Integrity Respect Professionalism and Compassion to provide youth prevention youth and adult outpatient sobering programs withdrawal management and co-occurring capable residential programs to support the well-being of women men youth LGBTQIA and BIPOC clients to live healthy fulfilling and constructive lives. HSI is an inclusive workplace and a learning community where our collective experiences
enrich each others growth.
The Compliance and Outcomes Manager implements all policies procedures and best practices ensuring all treatment at all levels are compliant with contractual State and Federal guidelines and providing the best care for our clients. The individual in this role will also monitor track appropriate systems and tools to ensure quality assurance/safety and deliverables are met.
How can you make a difference in peoples lives
In this role youll make a difference in the lives of people with substance abuse challenges and often with co-occurring conditions. Youll use and grow your skills in compassionate care crisis intervention and de-escalation in a supportive and inclusive work environment. Youll have the opportunity to provide our community with substance abuse treatment to help people who are just discovering possibilities in their journey going from a place of hopelessness to a place where they are valued and have the potential for a better life.
PRIMARY ACCOUNTABILITIES & RESPONSIBILITIES
Accountabilities:
- Quality Assurance/Quality Improvement (QAQI)
- Measuring Outcomes & Data Management
- Program Contractual Compliance
- Facilities Safety Quality. Facilities Repair & Maintenance (R&M). Facilities Management & Special Projects.
- Accreditation
Responsibilities:
Quality Assurance/Quality Improvement (QAQI)
- Under the direction of the Program Manager the Compliance and Outcomes Manager coordinates implements and oversees the Quality Assurance and Quality Improvement (QAQI) functions for the assigned program(s) or line(s) of service.
- Provide day-to-day implementation and management of QAQI functions for assigned program(s) including but not limited to conducting clinical documentation audits routine patient chart reviews environment of care quality monitoring and improvement assessments and coordination with stakeholder QAQI department authorities.
- Provides monthly QAQI reports to Program Manager. Reports include review and identification of potential deficiencies within clinical documentation and patient charts environment of care quality and outcome data quality.
- Coordinates with Program Manager to ensure effective implementation and monitoring of QAQI functions at the assigned program(s).
- Coordinates and facilitates QAQI inspections chart reviews and reporting to oversight agencies and participates in external auditing processes for assigned program(s). Develops audit response documentation including corrective action plans (CAPs) and performance improvement plans (PIPs) and submits to Program Manager and CSGSO for approval before submission. Performs timely completion and documentation of corrective actions and implements mechanisms to avoid repetition of negative audit findings.
- Assists the Program Manager and CSGSO to develop and implement policies procedures tools protocols and QAQI calendars to enhance productivity performance and efficiency related to QAQI functions.
- Serves as primary point of contact for oversight agencies for assigned program(s) and manages stakeholder communications related to QAQI functions under direction of Program Manager and CSGSO. Regularly attends QAQI meetings with funders and external stakeholders and communicates any updates or changes to staff at assigned program(s). Summarizes and relays this information to the Administrator.
- Coordinates with Program Manager for assigned program(s) to recommend improvements and corrective actions to be implemented at the assigned program(s).
Measuring Outcomes & Data Management
- Gather and manage program data used to enhance service delivery QAQI functions strategic planning regulatory compliance client outcomes and client satisfaction. Coordinates with IS Department as these processes relate to electronic systems.
- Analyzes and summarizes gathered data for assigned program(s) and reports to Program Manager and CSGSO and assists in the development of improvement recommendations to agency leadership.
- Generates QAQI outcomes and program compliance reports and deliverables for Program manager and CSGSO to compile and report to agency leadership. Ensures data integrity and availability for assigned program(s).
- Assist with development of procedures to collect regular feedback from clients staff and other stakeholders. Implement feedback mechanisms for assigned program(s).
- Serve as designated Privacy Officer for assigned program(s) and monitor compliance with all data security and privacy standards as defined by HIPAA 42 CFR and related County State and Federal privacy rules. Respond to requests for records and address any privacy/security related grievances or complaints under direction from Program Manager and CSGSO.
Program & Licensing Compliance
- Under the direction of Program Manager and CSGSO develops coordinates implements and monitors the maintenance of program contractual functions for assigned programs.
- For assigned program(s) monitor and maintain all documentation pertaining to staff certification and licensing TB testing and health screening CPR and First Aid Certification staff identification insurance and all other credentialing and personnel file requirements as defined by regulatory oversight agencies and stakeholders.
- Provide copies of credential documents to Human Resources. Coordinates with Program Manager on corrective actions related to personnel credentialing and record maintenance.
- Reports program licensing compliance deficiencies identified through routine monitoring of program operations and documentation to Administrator on a monthly basis and coordinates with Program Manager(s) for assigned programs to ensure timely correction and resolution of deficiencies prior to audit.
- Coordinates program inspections and facilitates external auditing processes. Develops written responses to audit reports including corrective action plans (CAPs) and performance improvement plans (PIPs). Ensures timely completion and documentation of corrective actions and implements mechanisms to avoid repetition of negative audit findings.
- Assist program development of policies procedures tools calendars and protocols to enhance licensing compliance operations for assigned programs.
- Conduct routine unannounced internal audits including chart reviews for program licensing compliance and communicate any findings to CSGSO and Program Manager in order to coordinate prompt resolution to identified deficiencies.
- Participate in weekly meetings with Program Leadership to coordinate program compliance efforts develop improved monitoring practices and receive regular feedback related to ongoing compliance issues.
- Maintain expert knowledge regarding program compliance standards and other stakeholder agencies when applicable.
Facilities Management
- Leverages the support of the ADPOSS to ensure facilities are adequately maintained.
- Ensures the successful operation of a ticketing system to organize and prioritize repairs
- Assist CSGSO and Program Manager in developing vendor partnerships to maximize quality cost & turn-around on repairs
- Maximizes facility safety via the fast turn-around of necessary repair & maintenance
Contract Compliance
- Under direction of CSGSO and Program Manager develops coordinates implements and monitors the maintenance of contract compliance functions for assigned programs.
- Reports contract compliance deficiencies identified through routine monitoring of program operations and documentation to Administrator on a monthly basis. Coordinates with Program Manager(s) for assigned programs to ensure timely correction and resolution of deficiencies prior to audit.
- Coordinates contract inspections and facilitate external auditing processes. Develop written responses to audit reports including corrective action plans (CAPs) and performance improvement plans (PIPs). Ensures timely completion and documentation of corrective actions and implements mechanisms to avoid repetition of negative audit findings.
- Assist in the development of policies procedures tools calendars and protocols to enhance contract compliance operations for assigned programs.
- Coordinate with Program Managers to support their communications with contract agencies to maintain strong stakeholder relationships and address updates to contract requirements/deliverables for assigned programs.
- Conduct routine unannounced internal audits including chart reviews for contract compliance and communicate any findings to in order to coordinate prompt resolution to identify deficiencies.
- Participate in weekly meetings with Program Leadership to coordinate contract compliance efforts across the organization develop improved monitoring practices and receive regular feedback related to ongoing compliance issues.
- Maintain expert knowledge regarding contract compliance standards as defined by contracting agencies. Coordinate with CSGSO and Program Manager to educate staff and ensure program operations remain consistent with current standards. Assist in the planning coordination and facilitation of organizational trainings or other communications needed to ensure ongoing contract compliance.
Utilization Management
- Monitor and manage collection of utilization management (UM) data for assigned program(s). Report UM data and make recommendations to ensure census goals are met and maintained for assigned program(s). Address and resolve UM data integrity and management issues as needed.
- Implement monitor and make corrective actions as needed to track individual client service authorizations and provide regular notifications to program staff to support timely authorization renewal to avoid lapse in services for assigned program clientele.
- Responsible for collecting organizing and reporting program census data reconciliation of services with billing entries in electronic systems and other program UM census revenue or service-related data. Data reported to the Finance Department is timely and accurate.
DISC Behavior/Communication Strengths:
- Driven: Having a hard-charging approach showing a sense of urgency and focusing on swift results which is crucial for leadership and decision-making.
- Daring: Being comfortable with taking risks and pitching bold ideas. This trait is important for
innovation and driving change within an organization.
- Forceful: Is outspoken assertive and willing to advocate strongly for beliefs. This trait is needed in roles where strong leadership and decision-making are required.
- Accommodating: be adaptable and open to others input this trait balances assertiveness Frank: communicates directly and gets to the point quickly. This honesty and clarity are valuable for effective leadership and transparent communication.
- Skeptical: questioning and cautious when evaluating new ideas. This trait helps in making well-considered decisions ensuring that potential risks are carefully analyzed
(knowledge and skills required to effectively perform the job)
- Interpersonal communication
- Motivating others
- Written communication
- Honesty/integrity
- Problem Solving
- Developing others
- Vision/planning
- Creativity/innovation
- Conflict resolution
- Delegation
- Valuing Diversity
- Ability to solve problems quickly.
- Ability to interface with community members CBOs Funders and all referral sources in a positive manner.
- The ability to balance the leadership is needed to move forward and compassion to facilitate the needs of a counseling staff.
- Ability to recognize stress factors in a crisis environment and find creative inexpensive ways to reduce them.
- Ability to control emotions in situations of conflict.
- Ability to handle multiple projects at one time.
- Ability to process and develop appropriate conclusions.
- Needs to be able to work in stressful situations where information is needed in a short period of time.
- Knowledge of best clinical practices
- Microsoft Office including word PowerPoint and Excel.
What else is required
- BA degree or equivalent training/experience as described below.
- Preferred 2 years of substance use disorder mental health or similar Quality Assurance and Compliance
- Preferred SUD or mental health certification with state certifying organization or professional board.
- Fluency in at least one of New Mexico threshold languages (Vietnamese Mandarin Cantonese Dari Arabic Swahili Kinyarwanda and Din (Navajo)
Compensation and Benefits
We are proud to offer a comprehensive benefits package to all full-time and part-time employees over 20 hours per week.
- Generous contribution medical dental Life and LTD for the employee and 50% for any dependent medical and dental coverage.
- PTO and Holiday pay.
- Retirement benefits after 6 months of service.
- Training and CEU opportunities.
And of course the opportunity to meaningfully contribute to a team of mindful caring and passionate people at work every day!
Salary: :$49920K-$62400K/ annually based on experience and qualifications. Available for a full-time position.
Horizon Services Inc. is an Equal Opportunity Employer.
Required Experience:
Manager
Employment Type
Full-Time
