Supervisor of Compliance and QI

Ottawa County•Holland, MI

5d•Onsite

About The Position

Under the direction of the CMH Chief Operating Officer, this individual serves two essential duties: COMPLIANCE and QI Supervisor. In this role, the Compliance Manager designs, implements, and supervises continuing compliance of the organization with local, state, and federal standards. The Health Information Supervisor ensures that all consumer records (paper and electronic) are maintained in accordance with Ottawa County, MDCH, and CARF standards and in compliance with the provisions of HIPAA and other federal standards (e.g. BBA). This is a full-time, benefited position working out of the James Street Complex located at 12265 James Street, Holland, MI. Typical working hours are Monday - Friday, 8:00 a.m. to 5:00 p.m.

Requirements

Master's degree in psychology, social work, public administration or related health and human services field with two years of relevant experience is preferred.
Bachelor's degree with two years of experience may be acceptable.
Must possess or acquire familiarity with standards as issued by: CMHOC, CARF, Department of Human Services, BBA, HIPAA, PIHP, OIG, MDEQ, MBRS, Office of Children and Adult Licensing, local municipalities, and the Michigan Department of Health and Human Services standards.
Thorough working knowledge of CMHOC policies and procedures, local, state, and federal codes, statutes, rules, and regulations governing safety and compliance. (Michigan Department of Health and Human Services, Michigan Mental Health Code, Medicaid Manual for Service Providers, BBA, HIPAA, Red Flag Rules, ADA, OIG, DEQ, OSHA/MIOSHA for health care practitioners, 42 CFR Part 2 and CARF).
Thorough working knowledge of the principles and practices of health information documentation and health information management.
Thorough working knowledge of program assessment and quality assurance principles, practices, protocols and instruments.
Computer literacy and working knowledge of word-processing, spreadsheet, database, imaging, and project management software as well as online learning systems.
Excellent organizational, time management, and project management skills.
Excellent verbal and written communication skills.
Shows willingness to learn and use new skills and takes regular advantage of internal and external training and staff development activities.
Must be able to perform essential job functions with or without reasonable accommodations, including, but not limited to, visual and/or audio logical appliances, and devices to increase mobility.

Nice To Haves

Lived experiences with mental illness, developmental disabilities, or substance use disorders are valued.

Responsibilities

Monitors compliance with established agency, county, PIHP, state, and federal standards across the network of providers.
Coordinates the development/implementation of the compliance program to ensure compliance with the standards established by the Michigan Mental Health Code (PA258of1974), Michigan Department of Health and Human Services (MDHHS) rules and regulations, the Ottawa County Mental Health Board, the Commission on Accreditation of Rehabilitation Facilities (CARF), and federal standards (e.g. HIPAA, BBA, DRA, OIG, 42 CFR Part 2).
Prepares, coordinates and acts as the primary liaison and lead during surveys and audits from the PIHP, MDHHS, and CARF.
Ensures completion of Corrective Action Plans and implementing Quality Improvement Activities for the organization.
Develops, supervises, and participates in the implementation of standard operating policies and procedures for the operation of community mental health services.
Investigates, documents, reports, and develops appropriate responses and protocols to prevent future occurrences of medication errors, injuries to consumers and staff, infection control and serious communicable disease incidents, biohazard incidents, weapons on-site, and other critical incidents and sentinel events.
Investigates, documents, reports and monitors billing issues, documentation issues and Fraud, Waste and Abuse reports.
Advises, participates in, and reports serious compliance violations to the CMH Compliance Committee.
Collaboratively works to ensure that all staff comply with training and continuing education requirements for maintenance of licenses and accreditation.
Collaborates with community mental health care providers to ensure proper adherence to Michigan Mental Health Code and federal and MDHHS rules and regulations in the delivery of mental health services.
Recommends Standards of Conduct, related policies, and procedures.
Monitors corporate-wide compliance plan for periodic updates when needed.
Oversees compliance investigations with law enforcement, corporate counsel, medical director, PIHP, human resources, and/or any other appropriate party.
Recommends reporting channels (e.g. Hotline) for use without fear of retaliation.
Maintains a working knowledge of relevant issues, laws, and regulations.
Designs, develops, implements, and maintains uniform policies and procedures for the documentation and maintenance of patient health information stored in all modalities (images, paper, and electronic).
Develops and implements quality assurance and quality control protocols for health information and case data management.
Develops proposals and recommendations to apply innovative technological solutions to health information processing and file maintenance issues in order to provide clinicians with timely access to complete, accurate, and up-to-date clinical information.
Works in collaboration with clinical managers, Information Technology and vendors/consultants, to design, develop, test, and implement the electronic medical records information system.
Supervises the work of medical record aides and assures necessary accommodations are in place (including coordination with job coaches as necessary).
Chairs and/or participates in a number of committees charged with evaluating and/or enforcing quality standards and compliance.
Provides direct supervision for subordinate staff in accordance with established county and CMH policies and procedures and all statutes and regulations governing the employment relationship.
Supervises professional and support staff, including hiring and termination procedures, providing training and work assignments, administering policies and procedures, reviewing and evaluating work performance, identifying training and development opportunities, and administering disciplinary actions.