Manager of Compliance, Quality and Patient Safety

North Central Health Care•Wausau, WI

2d•Onsite

About The Position

The Manager of Compliance and Quality is responsible for supporting the day-to-day operations of North Central Health Care's Compliance and Quality Department. This includes oversight and coordination of quality improvement initiatives, compliance support, regulatory readiness, client rights support, event reporting follow-up, emergency management, and environment of care activities. This role provides direct supervision and operational guidance to assigned Compliance and Quality team members. Working under the direction of the Director of Compliance and Quality, the Manager collaborates with program leaders, clinical teams, and operational departments to support regulatory compliance, patient/resident/client safety, documentation integrity, performance improvement, and organizational readiness. This position helps ensure that compliance, quality, safety, and risk prevention activities are implemented consistently across NCHC while supporting a culture of accountability, continuous improvement, and person-centered care.

Requirements

Bachelor’s degree in healthcare administration, human services, or a closely related field.
More than 3 years of experience in compliance, healthcare administration, human services, nursing, public health, or quality improvement.
Demonstrated experience with supporting quality improvement initiatives, regulatory readiness activities, audits, corrective action follow-up, event reporting, complaint resolution, or compliance-related projects.
Knowledge of CMS, Joint Commission, state regulations, and other accreditation standards.
Must possess a valid Wisconsin driver's license and maintain unrestricted driving privileges throughout employment and have use of a personal vehicle.
Must meet and continue to meet all requirements for insurability under the organization's vehicle insurance policy.
Must be authorized to operate any vehicle as required by the position.

Nice To Haves

Expertise in quality improvement methodologies (e.g., PDSA, Lean, Six-Sigma).
Experience in behavioral health, skilled nursing facility, hospital, community-based healthcare, or human services settings.
Leadership or supervisory experience, including experience coordinating staff, projects, audits, corrective action plans, or department-level initiatives.
Certification in quality, compliance, privacy, risk management, patient safety, emergency management, or healthcare leadership, such as CPHQ, CHC, CHPC, CHC-F, CPPS, Lean/Six Sigma, or related certification.
In evaluating candidates for this position, North Central Health Care may consider a combination of education, training, and experience which provides the necessary knowledge, skills, and abilities to perform the duties of this position.

Responsibilities

Collaborate with clinical, operational, administrative, and support service leaders to implement quality, compliance, risk, safety, and regulatory initiatives consistently across programs.
Coordinate emergency management, environment of care, and safety readiness efforts by providing operational oversight to EHS-related projects, drills, rounds, assessments, corrective action follow-up, and regulatory documentation under the direction of the Director.
Develop and maintain quality, compliance, and performance reports by reviewing dashboards, audit results, event trends, patient/resident/client experience data, and other indicators to support leadership decision-making and continuous improvement.
Educate and support staff and leaders on quality improvement processes, event reporting expectations, documentation standards, regulatory readiness, client rights processes, and compliance-related workflows.
Facilitate compliance operations and routine investigations by conducting fact-gathering, reviewing documentation, addressing minor privacy or compliance concerns, tracking corrective actions, and escalating high-risk matters to the Director of Compliance and Quality.
Interpret quality, compliance, and event reporting data to identify trends, monitor performance indicators, evaluate improvement opportunities, and recommend data-informed actions to leadership.
Lead and coordinate quality improvement initiatives across Behavioral Health, Skilled Nursing Facility, and other assigned programs to support patient/resident/client safety, service quality, regulatory compliance, and improved outcomes.
Manage complaint and grievance intake support, including serving as a secondary Client Rights Specialist when assigned, fielding initial concerns, supporting documentation, and assisting with follow-up in accordance with applicable client rights and organizational processes.
Monitor internal event reporting processes by reviewing reported events, assigning or requesting manager follow-up, tracking completion of corrective actions, and identifying trends that may require escalation or improvement.
Oversee compliance auditing and documentation review activities by supporting audit planning, reviewing audit findings, monitoring documentation accuracy and completeness, and partnering with leaders to address identified gaps.
Supervise and support assigned Compliance and Quality team members by assigning work, monitoring follow-up, supporting performance, and coordinating departmental priorities.
Support compliance operations and routine investigations by assisting with fact-gathering, documentation review, minor privacy or compliance concerns, corrective action tracking, and escalation of high-risk matters to the Director of Compliance and Quality.
Support regulatory and accreditation readiness activities, including survey preparation, mock surveys, regulatory audits, department readiness reviews, evidence collection, and follow-up with leaders on identified deficiencies.
May be required to travel to NCHC locations, community sites, or external meetings may be required.
Perform other related duties as assigned.
Manages a team of at least 3 Compliance and Quality staff.
Assign and evaluate work
Coach and mentor employees
Manage employee performance, partnering with HR when needed.
Review performance annually
Participate in the hiring process.