Director of Quality and Compliance

DePaul Community Resources

Director of Quality and Compliance

Roanoke, VA
Full Time
Paid
  • Responsibilities

    DePaul Community Resources seeks a full-time Director of Quality and Compliance.

    JOB SUMMARY:

    The Director of Quality and Compliance is committed to ensuring the highest level of care and safety within DePaul's programs through monitoring, evaluating, and identifying areas of risk and improvement related to client welfare and organizational well-being. The Director of Quality and Compliance is a primary resource on issues related to state licensure, human rights, Medicaid regulations, and best practices.

    SUPERVISION RECEIVED AND EXERCISED:

    The Director of Quality and Compliance will supervise the QI & Electronic Records Manager and the QI Specialist and report directly to the Vice President of Developmental Disabilities.

    ESSENTIAL FUNCTIONS AND DUTIES:

    This list is not an exhaustive & all-inclusive list of job responsibilities. The distribution of time allotted for any function or duty is subject to change with or without notice. Nothing in this job description restricts management's right to assign other responsibilities to this job or reassign them elsewhere at any time.

    Evaluate risk/liability related to service delivery and records, compliance issues/concerns, and identify opportunities for improvement

    Identifies potential areas of compliance vulnerability and risk; in consultation with the Vice Presidents (VP), Division Directors, and service leaders, develops corrective action plans and practices for resolution of problematic issues and provides general guidance on how to prevent or address similar situations in the future

    Collaborate with division vice presidents, directors, and service leaders regarding areas of compliance and quality, the need for a root cause process, and inform leadership about issues impacting compliance and best practices related to their service or department

    Serve as HIPAA privacy and security officer, including oversight of training for employees, sponsored providers, and resource parents

    Provides informal training to employees on regulations, accreditation standards, HIPAA, and best practices as requested and/or needed.

    Aids with curriculum development for training as requested

    Assist with data collection, aggregation, and analysis of DePaul's services, including but not limited to division and program outcomes summaries, internal incident reports, root cause analyses, external and internal audits, etc.

    Identifies opportunities for project improvement teams and leads or facilitates improvement teams as assigned

    Oversee and consult with the completion of improvement plans or corrective action plans

    Provide guidance and technical assistance regarding best practices in programs

    Assist with investigations or root cause analyses - in conjunction with support from a service leader - of critical incidents as assigned. If independent process and reports are needed, conducts the investigation and prepares reports

    Assist program and site leaders with debriefing after a root cause process, as well as ensuring root cause data information is used effectively to address quality and service improvement as needed

    Provide reports regularly and as directed or requested. Reports on serious incidents on a quarterly and annual (cumulative) schedule; Provides annual report of progress on a divisional quality improvement basis; Reports to the risk management committee quarterly. Reports related to internal investigations, root cause analysis, etc., as needed and requested

    Assist in the development of policies and procedures for each service component

    Participate in regular supervision with the Vice President of Developmental Disabilities

    Serve as a member of the Division Leadership Teams as requested, including providing information on program quality and best practices

    Participate in quarterly DePaul risk management team meetings, providing related program data from each division VP or program director and reporting risk management team feedback to the respective VP and /or division teams

    Review, analyze, interpret findings, and respond to internal administrative inquiries related to quality issues, audits, corrective action plans, root cause analyses, stakeholder satisfaction surveys, etc., as needed and requested. Offer support during external audits as required and/or requested

    Assist in strategic planning, as requested

    Responsible for the management and oversight of the DePaul electronic record system

    Coordinate and lead the DePaul accreditation standards process collaboratively with program leader.

    Maintain knowledge of division policies and procedures to ensure compliance with licensing and human rights regulations, HIPAA, DMAS, and accreditation standards

    Promote a culture of safety, compliance, continuous improvement, proactive response, engagement, performance excellence, person-centered supportive decision-making, and best practices

    KNOWLEDGE, SKILLS, ABILITIES & OTHER CHARACTERISTICS REQUIRED:

    Knowledge, skills, abilities, and other characteristics or KSAOs are attributes needed to perform a job that are demonstrated through qualifying training, education, and experience. This list is not an exhaustive & all-inclusive list of all KSAOs for this job.

    Knowledge of:

    Office and records administration techniques and procedures

    The structure and content of the English language, including the meaning and spelling of words, rules of composition, and grammar

    Microsoft Office Word, Excel, Powerpoint, Outlook, Sharepoint, Teams, and virtual meeting applications such as Zoom, WebEx, Google Meet

    DePaul's policies, procedures, and standard practices and the rules and guidelines established by regulatory and governing agencies

    Relevant policies, procedures, and strategies to promote the safety and protection of people, data, and property

    Methodologies and resources used to assess the needs of the listener or audience to share information or engage in ongoing communication

    Program planning and implementation, qualitative and quantitative performance analysis, and return on investment measurement techniques

    Skill/Ability to:

    Excel functions such as filter, sort, average, and sum

    Give full attention to what other people are saying, take time to understand the points being made, ask questions as appropriate, and not interrupt at inappropriate times

    Demonstrate verbal and written communication and body language that conveys information, ideas, or inquiries effectively and concisely that purveys professional composure, emotional intelligence, thoughtfulness, patience, and respect amidst change, ambiguity, and within the daily trajectories of work

    Demonstrate the use of logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems

    Demonstrate interpersonal and verbal skills to defuse emotional situations, calm upset individuals, allay fears, and lessen confusion

    Demonstrate ability to negotiate, mediate, facilitate, mentor, and coach

    Demonstrate ability to train and instruct others

    Manage the distribution of work, priorities, and projects for the department while simultaneously maintaining high-quality work product

    Monitor/assess the performance of staff and develop them based on individual conduct, skills, abilities, interests, and service needs

    Manage multiple priorities and complete assignments on time, accurately, and with attention to detail

    Operate a computer and proficient using electronic records systems, virtual meeting software, internet, department or program-specific software, and MS Office Suite applications, particularly Word, Outlook, and Excel

    Collect and analyze data

    Manage department budget and determine how finances will be spent and resources allocated and account for these expenditures

    Public speaking and delivering presentations to individuals and groups

    Develop and maintain professional working relationships and appropriate boundaries with individuals served, employees, community partners, and business associates, and work collaboratively in a team environment

    Communicate effectively in both oral and written form

    Make arithmetical computations and tabulations

    Develop objectives, evaluate effectiveness, and assess service plans for individuals served

    Analyze and prepare concise and accurate documents, reports, and correspondence

    Effectively market the programs and services of the department

    Communicate and interact effectively with members of the public

    Read and understand information and ideas presented in writing

    Analyze complex data and develop plans to address identified issues

    Establish program goals and objectives that support the strategic plan

    Plan, assign, train, and/or supervise the work of others

    Exercise sound judgment and critical thinking in decision-making and solving various work-related situations

    Operate standard office equipment such as telephone, calculator, printer, scanner, cellular phone, tablet, computer, postage machine, shredder

    Learn and adhere to policies, procedures, and guidelines established by DePaul, professional organizations, governing agencies, and local laws, statutes, regulations, codes, and standards related to the area of responsibility

    Assist with the general upkeep and cleaning of office areas and agency vehicles

    Other Characteristics:

    Demonstrate self-awareness, ongoing self-evaluation, and a commitment to being part of a diverse, equitable, respectful, and inclusive workplace where all people are valued

    Demonstrate professional composure in difficult and stressful situations

    Demonstrate the FIRST (fairness, integrity, respect, safety, trust) values in the daily trajectories of work

    Demonstrate professionalism regarding access to sensitive and confidential information related to employees, clients, and business records with no disclosure to others without needing to know.

    MINIMUM REQUIREMENTS TO APPLY:

    A Bachelor's degree in a human services field or an acceptable degree is required. Must have five years of experience in regulatory assurance in a human service organization.

    WORK ENVIRONMENT:

    The work environment characteristics described herein represent those an employee encounters while performing the position's essential functions. The employee regularly works in an office environment and occasionally in the field. Due to the nature of the work, the incumbent may be exposed to situations of a highly emotional nature; incumbents are expected to use verbal skills to resolve interpersonal situations to achieve desired results independently. Incumbents are exposed to various living situations and lifestyles. Work is generally completed regularly during weekdays; however, daily work hours will vary. Participation in an on-call rotation and completion of job duties outside of normally scheduled hours is required. Work is subject to frequent interruptions, and noise levels are varied based on the work locations.

    PHYSICAL REQUIREMENTS:

    The physical demands described herein are representative of those that an employee in this position must meet, with or without reasonable accommodations, to perform the essential functions successfully. Physical activities required are finger dexterity necessary to operate equipment used in the position, effective communication and seeing or hearing verbal cues. Walking from one-third to two-thirds of the time, sitting from one-third to two-thirds of the time, standing from one-third to two-thirds of the time, bending from one-third to two-thirds of the time, stooping rarely, lifting/pushing/pulling no more than ten pounds is required. When accessing various locations, the incumbent must climb stairs and ramps. This position requires driving approximately five percent of the employee's working time to various locations. Public transportation may not be available. Individuals needing reasonable accommodations should speak with their immediate supervisor/hiring manager.

    SPECIAL REQUIREMENTS AND QUALIFICATIONS:

    The following may be required after a conditional job offer: current DMV driving record with results that comply with insurer guidelines; drug and alcohol screening with satisfactory results stipulated by applicable governing, funding, or regulatory agencies; documentation of a PPD test, chest x-ray, or screening from a qualified medical professional indicating the absence of TB; criminal and child protective services background report. The applicant shall not have been convicted of any barrier crime(s) on the criminal background report. The applicant will have no founded disposition of child abuse or neglect as documented by the Child Protective Services background report.

    NOTE:

    This description provides information regarding the essential functions of the designated job and the general nature and level of work associated with the job. It should not be interpreted to describe all the duties whose performance may be required of such employees or be used to limit the nature and extent of assignments such an individual may be given.

    DePaul is committed to diversity, equity, and inclusion and is an Equal Opportunity Employer. E-Verify Participant.

    Flexible work from home options available.