Quality & Compliance Manager

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Full Time Full-Time Baltimore, MD, US

5 days ago Requisition

Salary Range: $90,000.00 To $ Annually

The Quality & Compliance Manager is responsible for leading People Encouraging People's quality improvement, compliance, accreditation, risk management, and performance measurement functions. This position partners with leadership to promote continuous quality improvement, ensure compliance with regulatory, contractual, and accreditation standards, and support organizational excellence through data analysis, performance monitoring, quality planning, and risk management.

The Quality & Compliance Manager provides leadership for the Agency's quality governance structure by overseeing quality improvement initiatives, chairing designated quality committees, coordinating organizational quality and compliance plans, monitoring client satisfaction and performance outcomes, and conducting quality audits to ensure compliance with clinical, operational, and documentation standards. Through collaboration with leadership and staff, this position fosters a culture of accountability, continuous improvement, and exceptional service delivery.

There are no staff persons reporting to this position. This role provides functional leadership to program directors, clinical leaders, and designated quality champions regarding organizational quality improvement and compliance initiatives.

• Serve as the Agency's Corporate Compliance Officer and Privacy and Security Officer, overseeing the organization's Corporate Compliance Program and ensuring compliance with HIPAA, the protection of Protected Health Information (PHI), and applicable federal and state privacy and security requirements.
• Lead the Agency's Continuous Quality Improvement (CQI) program and promote a culture of quality, accountability, and organizational excellence.
• Coordinate and maintain compliance with applicable federal, state, contractual, payer, and accreditation requirements, including CARF standards.
• Develop, implement, monitor, and evaluate the Agency's Quality Enhancement Plan, Performance Improvement Plan, Risk Management Plan, Corporate Compliance Plan, and other quality initiatives.
• Develop, monitor, analyze, and report organizational quality indicators, performance measures, and outcome data to executive leadership and committees.
• Prepare and maintain quality dashboards, scorecards, and performance reports to support organizational decision-making.
• Chair and facilitate quality-related committees, including the Incident Insight and Improvement Committee, Quality Enhancement Committee, Consumer Advisory Board, and other committees as assigned.
• Coordinate the Agency's incident reporting and review process, monitor trends, facilitate root cause analyses as appropriate, and oversee corrective action plans.
• Develop, administer, analyze, and report client, family, referral source, and stakeholder satisfaction surveys, using findings to drive quality improvement initiatives.
• Conduct routine quality assurance audits of clinical documentation, including Welligent electronic health records, assessments, treatment plans, progress notes, discharge documentation, medication administration records (MARs), medication documentation, and other clinical and administrative records.
• Monitor documentation quality and compliance with Agency policies, payer requirements, regulatory standards, and accreditation expectations, providing timely feedback and recommendations for improvement.
• Collaborate with program leadership to develop, implement, and monitor corrective action plans resulting from audits, quality reviews, incident analyses, accreditation findings, and regulatory reviews.
• Coordinate organizational readiness for accreditation surveys, licensing reviews, and external audits, including maintaining documentation, evidence, and compliance activities.
• Monitor key performance indicators and quality outcomes across all Agency programs and recommend strategies to improve service delivery and organizational effectiveness.
• Provide consultation, education, coaching, and technical assistance to leadership and staff regarding quality improvement, documentation standards, compliance requirements, accreditation standards, and best practices.
• Lead the Agency's policy management program by developing, reviewing, revising, and maintaining organizational policies, procedures, and protocols to ensure compliance with federal, state, payer, contractual, and accreditation requirements while supporting best practices and operational excellence. Coordinate the periodic policy review process with leadership and subject matter experts to ensure policies remain current, effective, and aligned with regulatory requirements, accreditation standards, and organizational goals,…