Compliance Specialist

Position Summary

This position holds shared responsibilities for overseeing and managing duties associated with maintaining the organization's compliance with regulations, standards, and procedures pertinent to the receipt of federal, state, and local funds. Focused on the provision of behavioral health services, the role entails meticulous attention to detail and adherence to regulatory frameworks. Additionally, the position involves collaborating with relevant stakeholders to uphold the highest standards of service delivery while aligning with funding mandates and guidelines.

Key Responsibilities

• Oversee the incident report process including training staff on filing and submitting incident reports, ensuring incident reports are entered completely and accurately, forwarding to all applicable staff for signatures, and reporting to the Ohio Department of Behavioral Health (Ohio DBH) as required.
• Review incident reports regarding safety in monthly safety committee meetings.
• Conduct an annual review of all incident reports to identify areas of concern and work with members of the CQI committee to develop a plan of action to address any areas of concern.
• If the incident involves a client death, request a coroner's report, and review the case with the Chief Medical Officer to determine if a death review is necessary.
• If required, coordinate the death review meeting, and take notes during the meeting.
• Maintain documentation within the designated electronic document management systems.
• Maintain, create, or redesign (as needed) satisfaction surveys distributed to clients and community partners/referral sources.
• Initiate targeted survey distribution periods at least bi-annually for client satisfaction surveys, and ongoing or as needed for community partners/referral sources.
• Enter paper survey responses or work with other identified staff to ensure proper data entry.
• Analyze/Review results and compile a report regarding findings.
• Share survey results with administration and department managers, as applicable.
• Review survey results and findings in monthly PI/CQI meetings.
• Develop a report regarding responses and plans to address areas of concerns from the survey results in collaboration with department managers.
• Receive, address, research, document and maintain all client or parent/guardian written or verbal grievance(s).
• Monitor and evaluate all Client Rights and Grievances policies and procedures.
• Report all grievances to appropriate Committee, CEO, Licensing/Credentialing Boards, and Human Resources Department, if applicable.
• Report all grievances to the MHRB on a monthly basis or as requested; and to TCN's Board of Directors quarterly as directed.
• Conduct Client Rights training to all new personnel during orientation and current staff on an annual basis.
• Conduct compliance training with personnel at hire and annually either in person or by an approved electronic or software platform.
• Participate in the annual review and update (as needed) of TCN Behavioral Health Services' policies and procedures.
• This may require being the lead on forming and managing meetings or committees during the review process.
• Attend and summarize community meeting minutes with action items, as applicable.
• Disseminate information to TCN leaders and employees, as applicable.
• Within the first 30 days of a new clinical employee's date of hire, conduct 2 clinical chart reviews (focus reviews).
• Conduct an additional chart review (focus review) 60 days after a new clinical employee's date of hire.
• Conduct clinical chart reviews (focus reviews) on a minimum of 2 charts a week.
• Complete observations on all clinical providers at least once every 6 months, including reviewing any documentation conducted during the observation.
• Write up a review/summary of the observation for the provider and supervisor to review.
• Oversee Additional Session Requests Procedure in the adult mental health department, as needed.
• Conduct a chart review when a provider submits a request for additional sessions.
• Within the review, ascertain the viability of the additional sessions request and propose alternative treatment recommendations where appropriate.
• Maintain all reviews within the designated electronic document management systems.
• When returned, ensure corrections are made to any areas of concern identified in the review.
• Run a report monthly regarding clients that are approaching or over 12 sessions to ensure providers are following the model and making requests, as needed.
• Assists with on-site surveys and other duties as needed or requested by the Corporate Compliance Officer.
• Maintains license or registration appropriate to profession and/or appropriate to job requirement, including appropriate amount of continuing education at all times of employment.
• Maintains agency-required annual training including client rights and grievances, safety training, infection control, and others as required by Ohio DBH, CARF, and/or other regulatory entities.
• Remains free from citations by other providers or by consumers for unethical practice and meets standards for own profession.
• Other job duties as assigned.
• Adheres to all organizational and departmental policies, complying with all behavioral and ethical expectations.
• Completes all agency-required trainings, including but not limited to client rights and grievances, safety training, infection control, etc.
• Demonstrates and supports the company core values TCN C.A.R.E.S. "Commitment, Accountability, Respect, Empathy, Service"

Qualifications

Minimum Qualifications:

• Education: Associates degree with licensure in behavioral health related field preferred.
• Experience: Three years in behavioral health and leadership experience preferred; three years in quality assurance/quality improvement activities required.
• Certification: N/A.
• Other: N/A.

Knowledge, Skills, & Abilities

Knowledge of: Safety rules and procedures, Agency policy and procedures, Regulatory Agency requirements, Documentation requirements.

Skills:

• Sound analytical skills
• Strong problem-solving skills.
• Strong interpersonal skills.
• Capacity to perform duties effectively under potential emotional stress and conflict situations.
• Proficiency in utilizing basic computer skills and office equipment for documentation and communication purposes.
• Practice of a client-focused approach, demonstrating active listening skills, reading comprehension, critical thinking, and leadership abilities.

Abilities:

• Multi-tasking.
• Seeing, hearing, and communicating information clearly.
• Demonstrating strong attention to detail.
• Following directions.
• Use of computer keyboard.
• Sitting for periods of time.
• Lifting up to 25 pounds.