Compliance Manager

Arizona Department of Administration•Phoenix, AZ

4d•$70,634•Onsite

About The Position

The Arizona State Hospital (ASH) provides inpatient psychiatric care to persons with serious mental illness who need long-term behavioral health care. ASH promotes hope and wellness for our patients and creates opportunities to participate in planning, delivering and evaluating services that assist with recovery. Treatment is individualized with goals that focus on education about an illness, instilling hope and improving one's overall quality of life. The Arizona State Hospital has a wide range of positions available, from our direct care staff, nurses and behavioral health technicians to social workers, rehabilitation specialist and security to name a few. The Arizona State Hospital also offers 12 hour shifts for our direct care staff as well as some alternative work schedules, flexible hours for non-direct care staff. We offer a robust benefit package, including the ADHS Student Loan Assistance Program where eligible employees can receive up to $437.50 per month for their outstanding student loans. Come check us out and see how you can make a difference in the lives of all Arizonans. The Compliance Manager coordinates with the Chief Compliance Officer (CCO) and other Compliance Managers to track the regulatory requirements for each licensed facility operated by the Arizona State Hospital. Conducts performance audits and mock surveys to evaluate ASH’s compliance with regulatory standards. Develops audit tools, collaborates with subject matter experts to conduct mock surveys, compiles findings and deficiencies, and presents results to the ASH Compliance Committee. Researches hospital regulations, including state licensing rules, The Joint Commission accreditation standards, and Centers for Medicare & Medicaid Services (CMS) regulations. Supports ASH departments by providing research findings, feedback from mock surveys, and technical assistance to maintain regulatory compliance. Participates in hospital committees and meetings, including the Environment of Care Committee, Quality Department committees, and the Complaints, Grievances, and Appeals Committee. Conducts routine rounds throughout the ASH campus and patient units to assess compliance and address staff questions. Provides backup support to the CCO by serving as a point of contact for CMS, The Joint Commission, and state licensing surveyors. Assists the CCO in developing plans of correction in response to survey findings. Conducts focused audits at the request of the Executive Management Team and other departments. Facilitates annual contract and performance evaluations for ASH contractors and vendors. Participates in periodic meetings with ADHS Procurement to provide feedback on contract monitoring and enforcement. Reviews ASH policies, guides, and manuals to ensure alignment with regulatory requirements.

Requirements

Knowledge of health care policy review and development.
Knowledge of Joint Commission standards, Medicare regulations, and State licensing rules.
Knowledge of audit practices.
Knowledge of health records, including electronic health records.
Knowledge of contract development, oversight, and enforcement.
Knowledge of Performance Management (PM), and Continuous Quality Improvement (CQI) and Lean methodologies.
Skill in developing audit tools.
Skill in researching and interpreting health care regulations.
Skill in communicating effectively with other departments regarding deficient practices/non-compliance.
Skill in presenting findings in an oral and written format.
Ability to apply hospital rules, regulations, and standards to ASH policies and procedures.
Ability to draft plans of correction.
Ability to collaborate with other departments in implementing plans of correction.
Ability to represent ASH during surveys with regulatory entities.
Ability to objectively evaluate contract performance.
Ability to support a diverse multi-cultural workforce that reflects the community, promotes equal opportunity at all levels of public employment, and creates an inclusive work environment that enables all individuals to perform to their fullest potential free from discrimination.
Must be able to obtain a valid Level One Fingerprint Clearance Card pursuant to A.R.S. § 41-1758.07.
Possession of and ability to retain a current, valid state-issued driver’s license appropriate to the assignment.
Acceptable driving records.
Completion of any driver training.
Successful completion of the Electronic Employment Eligibility Verification Program (E-Verify).

Nice To Haves

Bachelor's degree in health related field and 4 years’ experience working with regulatory agency rules, regulations, and standards.
A Master's degree in a field appropriate to the assignment may substitute for one year of the required experience.

Responsibilities

Conducts performance audits/mock surveys to evaluate ASH's compliance with regulatory requirements. Develops audit tools, collaborates with subject matter experts to conduct mock surveys, compiles survey findings and deficiencies, and reports findings to the ASH Compliance Committee.
Researches hospital regulations, including state licensing rules, The Joint Commission accreditation standards, and Centers for Medicare and Medicaid (CMS) regulations. Supports other departments at ASH by providing research findings, feedback from mock surveys, and technical assistance to sustain compliance with regulatory requirements. Reviews ASH policies, guides, and manuals for consistency with regulatory requirements.
Participates in hospital committees/meetings, including the Environment of Care Committee, Quality Department committees, and Complaints, Grievances, and Appeals Committee.
Conducts periodic rounds throughout the ASH campus and patient units to evaluate compliance and address staff questions.
Provides backup support to the CCO by serving as a point of contact for CMS, The Joint Commission, and state licensing surveyors. Coordinates with the CCO in the development of plans of correction in response to survey findings.
Conducts focused audits, as requested by the Executive Management Team and other hospital departments.
Facilitates contract evaluations/performance evaluations of ASH contractors/vendors, which must be completed at least annually. Participates in periodic meetings with ADHS Procurement to provide feedback on contract monitoring and enforcement
Other duties as assigned as related to the position (typically 5% - 10%)

Benefits

Affordable medical and dental insurance plans
Paid vacation and sick time
Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child (pilot program)
10 paid holidays per year
Wellness program and plans
Life insurance
Short/long-term disability insurance
Defined retirement plan
Award winning Infant at Work program
Credit union membership
Transit subsidy
ADHS Student Assistance Pilot Program