Chief Compliance & Quality Officer

JOB DESCRIPTION:

The Chief Compliance and Quality Officer (CCQO) is responsible for designing, implementing and monitoring the processes by which PHRI will comply with all applicable laws and regulations. This role is responsible for driving PHRI’s Code of Conduct, internal and annual assessments including the periodically review the Company’s compliance with State and Federal regulatory requirements and the Company’s policies and procedures.

The role will focus on providing guidance to all clinical and administrative departments. As a member of the PHRI Leadership Team, the CCQO will use best practice standards to build and lead robust compliance and quality programs that ensure safe, compliant, and high quality workplace and treatment environment for the communities PHRI serves. This role also maintains a working environment that promotes ethical values, exemplary behavior and compliance. The CCQO will have dotted line reporting to PHRI’s Board of Directors and will apprise the Board of changes in regulation and accreditation standards which may impact the application of services.

DUTIES AND RESPONSIBILITIES

• Responsible for clinical quality, consumer safety, and risk management activities across PHRI’s locations – community clinics, SUD and respite programs, and residential housing programs. 

• Accountable for designing systems to ensure a state of continual regulatory, licensure, and accreditation compliance as well as consumer safety programs. 

• Leads a culture of quality consumer safety across PHRI grounded in evidence-based practices. 

• Accountable for accreditation, licensing, and regulatory activities established by CARF, state, and federal regulators among others.

• Responsible for planning and conducting education and training programs that support the regulatory process and compliance programs. Identifies and assesses quality and risk information to collaborate and prepare corrective action plans for compliance. Tracks and trends regulatory compliance issues and identifies resources to correct deviations from regulation. 

• Fosters a culture of readiness and continuous improvement by building strong relationships with clinical staff to identify, prioritize, and resolve compliance and safety concerns for PHRI consumers and employees. 

• Ensures policies and procedures are accurate and reflective of regulatory and accreditation compliance standards.  Advises leadership and employees on the development of standard operating procedures and workflows to create a safe and high-quality service delivery and work environment. 

• Chairs Compliance Committee including the adoption of compliance policies, review and approval of the employee education and training program, the identification of internal audit priorities and risk action areas and oversight of any corrective action plans.

• Maintains corrective action procedures to correct inputs that would expose a potential problem related to the service that we provide to our members.

• Works with organization administration, legal counsel, and other related parties to represent the organization's information privacy interests with external parties (state or local government bodies) who undertake to adopt or amend privacy legislation, regulation, or standard.

• Evaluates the organization's existing policies and procedures for HIPAA compliance by performing HIPAA risk assessments.

• Collaborates with plan management, administration, and legal counsel to identify and address privacy policies and procedures that require improvement.

• Develops and assists with implementation of new and updated policies and procedures.

• Assesses methods and procedures used to store and transmit PHI; identifies security or other compliance risks and researches and recommends improvements.

• Manages all required breach determination and notification processes under HIPAA and applicable State breach rules and requirements.

• Establishes and administers a process for investigating and acting on privacy and security complaints.

QUALIFICATIONS

• Master’s degree in business administration, healthcare administration or management, nursing, public or behavioral health strongly preferred.