Quality and Compliance Specialist

Quality and Compliance Specialist (Project Management)

Nature of Work:
The Quality and Compliance Specialist is responsible for monitoring, supporting, and improving agency-wide quality and compliance functions. This position ensures compliance with all federal, state, and internal regulations, including Medicaid Waiver and ICF services, HIPAA, and other licensing bodies. The Specialist conducts audits and quality reviews, participates in licensing and fire safety inspections, supports accurate documentation, identifies risk trends, and ensures the agency operates in an ethical, person-centered, and legally compliant manner.

Conduct internal audits of program and administrative records to ensure compliance with DHHS, OADS, CMS, HIPAA, licensing standards, and agency policies.

Track incident reporting, documentation practices, and service delivery to identify areas of concern or non-compliance.

Monitor documentation and records related to Individual Service Plans (ISPs), Service Implementation Plans (SIPs), and Individual Needs Assessments (INAs) to ensure completeness, accuracy, and regulatory compliance.

Enter and maintain documentation in state and agency systems (e.g.,Evergreen, iCare Manager, Therap, Atrezzo) as required; follow up on discrepancies.

Participate in licensing reviews, Fire Marshal inspections, and other external surveys, assisting with preparation, documentation, and follow-up actions.

Monitor Incident reports for appropriate resolution and documentation.

Support the agency's HIPAA compliance efforts by maintaining confidentiality and helping identify potential privacy concerns.

Identify and track trends in quality or compliance issues and bring concerns to the Director of Quality Improvement and Compliance.

Assist in developing corrective action plans and ensure proper follow-up and documentation.

Maintain systems for tracking unmet needs and service implementation progress; communicate updates to relevant teams.

Communicate and collaborate with Residential, Shared Living, Case Management, Clinical, and Administrative staff to resolve documentation or compliance concerns.

Act as a resource on documentation systems and quality standards.

Participate in internal committees such as Safety, Human Rights, and Risk Management as assigned.

Ensure that all compliance and quality documentation is organized, up-to-date, and securely maintained.

Support agency readiness for audits, inspections, and external reviews through thorough and timely recordkeeping.

We take ownership of our actions, follow through on commitments, and hold ourselves and each other to high standards.

We embrace change, stay open to feedback, and grow through learning and evolving together.

We work as one team, listening, supporting, and building on each other's strengths.

We support individuals in making their own choices, fostering independence, self-expression, and valuing every voice and experience with respect and empathy.

We believe in the power of connection and community. We are dedicated to serving, placing the needs and well-being of those we support at the center of all we do.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time.

Ability to work flexible hours, including occasional evenings or weekends, based on agency needs.

Travel between agency locations as necessary.

Maintain strict confidentiality and demonstrate a high standard of ethical and professional conduct.

Ability to remain in a stationary position (sitting or standing) for extended periods.

Ability to move throughout office spaces, program sites, and residential environments.

Occasionally lift and carry items up to 35 pounds (e.g., files, laptop, audit materials).

Must be able to…