Director of Compliance and Quality Improvement
- Experience Level
PURPOSE OF POSITION: Under the direction of the Assistant Executive Director, the Director of Compliance & Quality Improvement is responsible for overseeing and managing required contractual, regulatory, and accreditation compliance of all CHGA programs. The position ensures the Board of Directors, management and employees are in compliance with the rules and regulations governing CHGA programs. This position is responsible for ensuring compliance with all internal and external program standards, to promote continuous quality improvement for Covenant House Georgia programs and this position implements and monitors effective agency-wide data collection and reporting systems.
ESSENTIAL DUTIES AND RESPONSIBILITIES: Covenant House Georgia reserves the right to unilaterally modify, remove, or add to any of the following:
- Serves as the staff lead at CHGA on all program compliance systems and activities.
- Develops, implements, maintains and revises as necessary tools and other systems, electronic and otherwise, to ensure CHGA is meeting the standards of government funders, regulatory bodies, accreditation entities (e.g., Praesidium), and any other organization or system that has oversight over CHGA program operations.
- Manages all site visits from external auditors, ensuring that the appropriate staff, including senior leaders, are involved as necessary.
- Develops and maintains a “dry audit” and “live audit” calendar that is kept up-to-date and communicated to necessary internal parties.
- Ensures the provision of clear and understandable reports on internal audit findings that are easily accessible to program leaders and their staffs, and, in coordination with program leadership, ensures that any corrective action needed is fully implemented.
- Develop, in conjunction with other program and administrative staff, corrective action plans in response to external and internal monitoring activities and maintain records of these activities.
- Creates, maintains and revises as needed documentation needed for the efficient operation of programs (e.g., program manuals, process flowcharts, etc.).
- Works collaboratively with the HR Manager to ensure policies and procedures and other relevant documents on the All Staff Shared Drive are complete and current, and that all staff have access to all existing CHGA policies and other relevant documents.
- Collaborates with the HR Manager to ensure staff is adequately trained on all CHGA policies and procedures.
- Provides ongoing coaching and technical assistance to programs on contract and regulatory compliance issues.
- Responsible for the oversight of investigations of the Child Protection Officer’s duties and responsibilities with some ability to delegate the investigation process to an appropriate senior leader.
- Manages the CH Incident Reporting system including ensuring all documentation and any required internal and/or external communications regarding incidents are conducted timely and completely.
- Serves as the CHGA’s HIPAA Privacy Officer by overseeing all activities related to the development, implementation, and maintenance of CHGA’s policies and procedures covering the privacy and breach of client health information. Specific responsibilities including, but not limited to:
- Develop policies and procedures for staff training related to the privacy and breach of client protected health information (PHI);
- Oversee, direct and ensure the delivery of initial and ongoing privacy and breach trainings to all staff members;
- Serve as the contact person for client complaints and reports of breaches
- Ensure the capture and storage of client PHI for the minimum period required by law:
- Ensure compliance with all applicable Privacy Rule and Breach Rule requirements and work with managers to ensure the organization maintains appropriate privacy and confidentiality notices, forms and materials.
- Collaborates with the Assistant Executive Director on matters relating to building compliance and standardization of food safety processes within CHGA
- Ensures compliance with policies and best practices relating to serving LGBTQ youth.
- Serve as ETO (Efforts to Outcome) & Client Track Administrator for Georgia. Responsible for educating staff on the use of ETO & Client Track as well as develop systems for ongoing training.
- Assist program staff in using insights gained from data analysis in order to improve programs.
- Upholds Covenant House Georgia standards of conduct, policies and procedures at all times.
- Models appropriate, professional behavior for staff to establish and maintain superior services to youth in a safe and inviting atmosphere.
- Ensures that all buildings and surrounding areas are safe and free from any conditions that may cause harm or danger to youth, staff, volunteers, or visitors.
- Ensures compliance of files in accordance to specific city, state and Federal guidelines.
- Participates in other CHGA programs and activities as required.
- Establishes and maintains an effective working relationship with co-workers, supervisors, representatives of other agencies, and the public.
- Effectively communicates, verbally and in writing, with both internal and external individuals and/or businesses.
- Responds in a timely manner to emergencies and resolve issues.
- Performs all other duties as assigned.
SUPERVISORY DUTIES: This position supervises Quality Improvement Specialist. This position is responsible for approving staff’s time.
EDUCATION & EXPERIENCE: Bachelor’s degree required or Master’s degree in a related field preferred. 3-5 years of experience in a compliance or regulatory role. Demonstrated skill and experience in analyzing and problem solving complex problems and systems. Strong computer skills; experience using relational databases and statistical packages to collect and analyze data, and disseminate findings to improve processes, policies, quality of care, and employee performance.
- Strong communication & interpersonal skills
- Flexible, amiable, & willing to work as a team player
- Excellent organizational, written, and verbal skills with the ability to work independently
- Strong computer skills
- A “systems thinker” who excels at synthesizing and organizing large amounts of complex information.
- Highly professional with the ability to establish and maintain productive relationships with colleagues as well as federal, state and local contract auditors.
- Extremely discreet when working with sensitive and personal information
- Ability to remain calm while handling high risk or crisis situations.
- Has insight into problems and the ability to develop workable alternatives.
- Understands and abides by Mission Statement, policies and procedures and is knowledgeable and complies with federal, state, and local laws that govern business practices as well as all accreditation standards that apply to the position.
- Maintains strict confidentiality when working with sensitive information.
WORK ENVIRONMENT/PHYSICAL DEMANDS:
- Ability to work a flexible schedule as needed.
- Ability to work standing, walking, and/or sitting a minimum of 8 hours per day/shift.
- Ability to drive agency or personal vehicles to transport items and/or persons.
- Valid Georgia Driver’s License with acceptable driving record.
- Ability to travel as needed for training or to fulfill job requirements.
- Typically sits for extended periods at a computer workstation.
- Must be able to see, hear, touch, feel, lift (up to 20 - 50 lbs.) and stand for short periods of time.