Quality Improvement and Compliance Analyst

Suncoast Center•St. Petersburg, FL

About The Position

Assist the Chief Compliance Officer with drafting, reviewing, and maintaining agency policies, procedures, manuals, and operational guidelines to ensure alignment with federal and state regulations, HIPAA requirements, accreditation standards, and contractual obligations. Analyze quality audits, incident reports, and performance data to identify trends, recurring deficiencies, and systemic performance issues; assist in developing and monitoring Quality Improvement Plans and corrective action plans. Collect, analyze, and present data related to key performance indicators (KPIs), including quality audits, patient outcomes, client satisfaction surveys, safety incidents, and compliance metrics. Support accreditation and regulatory readiness activities, including mock audits, gap analyses, evidence tracking, and follow-up on corrective actions for CARF, state monitoring visits, and funder reviews. Assist with tracking contract deliverables, reporting deadlines, and quality requirements to support timely and accurate funder and regulatory submissions Migrate, organize, and maintain approved compliance-related documents, policies, procedures, and accreditation evidence from the Agency Share Drive to Microsoft 365, ensuring appropriate version control, document governance, and accessibility of current documents. Serve as the senior/lead investigator supporting the Chief Compliance Officer in the review and investigation of compliance complaints, including conducting detailed reviews of electronic health record documentation (Avatar), gathering relevant data, and summarizing findings to support compliance determinations and corrective actions. Provide project management and administrative support to the Chief Compliance Officer to reduce executive-level administrative workload and support agency-wide quality and compliance initiatives. Completes clinical quality reviews to ensure adherence to quality standards. Prepares reports and communicates outcomes of quality reviews and activities. Documents and tracks internal audits and other quality assurance projects. Participates in the internal Peer Review process and analyzes summary reports to ensure programs meet standards across all quality indicators. Ensures areas noted to have an opportunity for improvement are addressed and that improvement is sustained over time. Offers quality improvement suggestions on project protocols and processes; facilitates quality improvement plan in conjunction with Manager. Generates utilization reports and demonstrates the ability to interpret and analyze data in order make quality recommendations regarding client care. Works independently in gathering information from reviews and takes the initiative to seek information from members of the treatment team when needed. Has a thorough knowledge of all Agency programs and admission criteria and is able to recommend appropriate levels of care and time frames when appropriate. Adheres strictly to rules of discretion, tact and confidentiality. Assists leadership with project management and integration. Other duties as assigned. Incident Report Tracking as required.

Requirements

Master’s degree in Social Services.
Must be able to read and comprehend written instruction.
Has mental health experience in a significant administrative or clinical position.
Possess excellent computer skills and experience with Excel spreadsheets.
Department of Health Florida State License required
At least three years’ experience in a mental healthcare environment with exposure to clinical review.
Must be able to analyze complex issues and offer creative solutions, must have strong communication skills and strong orientation to client care in accordance with agency values.
Must be 21 years of age.
Negative Drug Screening prior to hire and throughout employment.
Clear Criminal Background Check throughout employment with Suncoast Center and local checks prior to hire and annually along with DCF Level II prior to hire and as required by DCF, and Must have valid Florida Driver’s License Motor Vehicle checks prior to hire and annually with acceptable driving record maintained throughout employment along with reliable vehicle, valid registration, and valid vehicle insurance. (must be in compliance with Florida Laws and Administrative Codes with fingerprinting and determined to be of good moral character).
Must have excellent computer skills and ability to work in the Agency electronic medical record and in Microsoft Word. Also must be able to create and work in Excel, creating and updating spreadsheets in order to enter auditing results and summary reports to present to management and external organizations.

Responsibilities

Assist the Chief Compliance Officer with drafting, reviewing, and maintaining agency policies, procedures, manuals, and operational guidelines to ensure alignment with federal and state regulations, HIPAA requirements, accreditation standards, and contractual obligations.
Analyze quality audits, incident reports, and performance data to identify trends, recurring deficiencies, and systemic performance issues; assist in developing and monitoring Quality Improvement Plans and corrective action plans.
Collect, analyze, and present data related to key performance indicators (KPIs), including quality audits, patient outcomes, client satisfaction surveys, safety incidents, and compliance metrics.
Support accreditation and regulatory readiness activities, including mock audits, gap analyses, evidence tracking, and follow-up on corrective actions for CARF, state monitoring visits, and funder reviews.
Assist with tracking contract deliverables, reporting deadlines, and quality requirements to support timely and accurate funder and regulatory submissions
Migrate, organize, and maintain approved compliance-related documents, policies, procedures, and accreditation evidence from the Agency Share Drive to Microsoft 365, ensuring appropriate version control, document governance, and accessibility of current documents.
Serve as the senior/lead investigator supporting the Chief Compliance Officer in the review and investigation of compliance complaints, including conducting detailed reviews of electronic health record documentation (Avatar), gathering relevant data, and summarizing findings to support compliance determinations and corrective actions.
Provide project management and administrative support to the Chief Compliance Officer to reduce executive-level administrative workload and support agency-wide quality and compliance initiatives.
Completes clinical quality reviews to ensure adherence to quality standards.
Prepares reports and communicates outcomes of quality reviews and activities.
Documents and tracks internal audits and other quality assurance projects.
Participates in the internal Peer Review process and analyzes summary reports to ensure programs meet standards across all quality indicators.
Ensures areas noted to have an opportunity for improvement are addressed and that improvement is sustained over time.
Offers quality improvement suggestions on project protocols and processes; facilitates quality improvement plan in conjunction with Manager.
Generates utilization reports and demonstrates the ability to interpret and analyze data in order make quality recommendations regarding client care.
Works independently in gathering information from reviews and takes the initiative to seek information from members of the treatment team when needed.
Has a thorough knowledge of all Agency programs and admission criteria and is able to recommend appropriate levels of care and time frames when appropriate.
Adheres strictly to rules of discretion, tact and confidentiality.
Assists leadership with project management and integration.
Other duties as assigned.
Incident Report Tracking as required.