QUALITY ASSURANCE AND COMPLIANCE MANAGER

Apis Services Inc•Shelby, OH

About The Position

In conjunction with the Executive Director of Quality & Compliance and program leadership team, verifies licensing, contractual, and accreditation compliance. This individual will establish and maintain systematic processes for on-going monitoring and evaluation of compliance of the program. The Senior QCS functions within a dual-reporting structure: Functionally reports to the Executive Director of Quality & Compliance for independence, oversight, and transparency. Operationally accountable to the Program Executive Director for timely communication, issue resolution, and day-to-day coordination.

Requirements

Bachelor's degree in social sciences, healthcare, behavioral health or related field and five years related experience OR Master’s degree and three years of experience.
Knowledge of the principles and use of tools used for data collection, data analysis, and performance improvement.
Knowledge of applicable licensing (e.g., DHS, OHS, TDFPS), contractual (e.g., MD DJS, CO DYC), accreditation (e.g., JC) standards.
Knowledge of the principles and practices related to the residential treatment of delinquent and dependent youth.
Ability to formulate and/or revise policies that meet licensing, contractual, and accreditation standards.
Ability to communicate effectively, both orally and in written form, with a diverse group of people including regulatory agency representatives, employees, clients, governing body members, and the general public.
Ability to self-start, work independently and adhere to timelines on a consistent basis with a minimum of assistance and supervision.
At least twenty-one (21) years of age
Criminal clearances (Act 33 and 34, specific State & child clearances and, if necessary, FBI)
Valid Drivers’ License from employee state of residence, valid and current vehicle registration, and insurance
Ability to work with computers and the necessary software typically used by the department.
Non-communicable diseases and physical exam.
Excellent written and verbal communication skills
Ability to convey clinical conceptualizations adequately through written and spoken language.
Ability to write complex evaluations and correspond with treatment team members and stakeholders.
Adequate abstract reasoning skills for case conceptualization.
High level Knowledge of Microsoft Word, Excel, and Outlook

Responsibilities

Prepares for and coordinates all licensing inspections, contractual reviews, and accreditation surveys.
Acts as internal liaison and contact person for all licensing, contractual, and accreditation representatives.
Coordinates development of and submits all action plans to address licensing, contractual, and accreditation citations or areas of non-compliance; monitors the implementation of action plans to verify compliance.
Reviews revisions to policies to verify they meet licensing, contractual, and accreditation requirements; maintain the policy and procedure manual for the facility.
Functions as the HIPAA Compliance Officer for the facility.
Prepares meeting agendas, coordinates meetings, maintains meeting minutes, and develops other documentation related to on-going monitoring and evaluation of the program.
Report critical incidents to outside agencies and oversight teams in accordance with regulations.
Collect, track, and assign staff responses to youth grievances, requests to talk, and medication request forms; ensure timely follow-up and resolution.
Respond to insurance complaints and provide documentation support.
Facilitate internal and external audits, ensuring timely submission of requested materials.
Draft and track corrective action plans in response to compliance findings; monitor progress and report updates.
Collects and maintains data for licensing, contractual & accreditation standards and performance improvement.
Prepares reports, data displays, charts, graphs, and other illustrations to support data collection, data analysis, and performance improvement.
Provides technical assistance and education to facility staff on licensing, contractual, and accreditation standards, including as-needed in-service training regarding the implementation of licensing, contractual, and accreditation standards.
In Ohio, this position is designated as the PREA Coordinator responsible for oversight of the PREA Compliance and directing the Abraxas PREA program.
Develops, implements, and oversees Abraxas’ efforts to comply with the Prison Rape Elimination Act (PREA) in each of the residential programs.
Develops PREA training curricula to meet national PREA standards for basic and specialized trainings required by the PREA standards.
Provides timely and informative status reports to the Executive Director of Q&C on PREA compliance issues discovered through internal compliance activities, facility walkthroughs and audits, or other means.
Provides guidance to other PREA compliance staff at Abraxas.
Develops, coordinates, and oversees the PREA audit schedule, to ensure compliance with PREA and Department of Justice (DOJ) auditing standards.
In partnership with the Q&C team, conducts pre-audit assessments of Abraxas facilities and reviews facility pre-audit questionnaires and supports documentation in advance of scheduled external PREA audits.
Collects, analyzes and produces statistical reports required by the PREA standards. Maintains oversight of the PREA data collection and retention systems.
Produces annual compliance monitoring reports for each facility. Reports non-compliance of contracted sites to the Executive Director of Q&C.
Coordinates with outside entities such as victim advocates, medical and mental health providers, investigative agencies, prosecutors, and others as required to meet PREA compliance.
Assume other specialized compliance responsibilities in areas aligned with the individual’s expertise and organizational needs, including but not limited to regulatory interpretation, accreditation standards, clinical documentation oversight, incident management, or quality improvement initiatives.
Supports the Abraxas philosophy and mission and promotes the Seven Key Principles of care.