Director of Compliance (Part Time)

Addiction Recovery•Crownsville, MD

About The Position

Hope House is seeking a Director of Compliance to help navigate the complexities of compliance and accreditation. This role provides advanced support to the Executive Director and the organization, focusing on the management of compliance, regulatory bodies, and essential reporting.

Requirements

Bachelor’s Degree; preferably in Healthcare Management
Previous experience in a compliance capacity
Knowledge of laws/regulations that impact a healthcare environment
Strong written and oral communication skills
Administrative supervisory experience
Strong computer skills

Nice To Haves

Preferred previous experience in a non-profit environment

Responsibilities

Develops and reviews company policies annually and as needed.
Regularly audits company procedures, practices, and documents to identify possible risks.
Oversees the Survey Monkey domain, including designing/redesigning questionnaires, analyzing data, and adding it to scorecards.
Monitors emergency drills for compliance with CARF requirements.
Collects and analyzes AMA and Staff discharge information.
Collects and accurately enters client success/retention rates on scorecards.
Assists with data collection regarding nosocomial and community-acquired infection rates and types.
Completes quarterly and annual analysis of grievances.
Maintains the updated Corporate Compliance Plan.
Serves as the Health and Safety/Risk Officer, conducting quarterly meetings to identify risk areas.
Collects and analyzes debriefings following critical incident reports.
Determines if a Root Cause Analysis (RCA) is required and conducts meetings in a timely manner.
Pulls quarterly data for CQI meetings, updating plans and analyses, and creating pie charts.
Designs, prints, and displays quarterly pie charts at each location.
Completes data on performance measurement indicator scorecards.
Completes annual performance measurement and management analysis.
Collects and maintains complaints and grievances, including investigation needs and follow-up.
Oversees internal inspection completion, including maintaining the annual schedule, assigning individuals, entering data into Survey Monkey, creating and assigning action plans, and conducting initial follow-up.
Completes applications for State licensing and CARF accreditation in a timely and efficient manner.
Maintains updates to CARF standards and communicates updates and action plans to personnel.
Advises management on the company’s compliance with laws and regulations.
Maintains Executive Committee meeting minutes and facilitates CARF updates/discussion.
Maintains the schedule for CQI meetings, prepares information to present, and completes CQI meeting minutes.
Completes department audits prior to CARF surveys or as needed to ensure compliance with standards.
Completes the Quality Improvement Plan after receiving the CARF Survey Report.
Schedules and leads annual meetings to complete assessments for new fiscal year plans and the completion of new plans, including performance measurement scorecards.