Director Of Compliance

The Director of Compliance works with Beacon of Hope (BOH) staff to ensure programs remain in compliance with applicable regulatory standards set forth by the New York State Office of Mental Health (OMH) and provides supervision to the Quality Improvement Manager. Major areas of responsibility include serving as a liaison with external regulatory entities, assessing the quality of program services, facilitating staff development, ensuring HIPAA and Corporate Compliance, and performing Administrative and/or program related duties as directed.

The salary for this position is: $115,000 - $120.000 annually.

Location: 2510 Westchester Avenue, Bronx, NY

Department and Systems

• Lead the Quality Improvement Department and supervise the Quality Improvement Manager
• Serve as BOH's representative and gatekeeper for regulatory entities and external provider support systems to fulfill compliance requirements, support care coordination, submit reports and maintain operations
• Manage BOH's electronic health record by serving as an internal Help Desk for staff and communicating with the vendor to troubleshoot issues and plan for changes
• Oversee BOH's participation in Regional Health Information Organizations, provide training to staff around such, and ensure all required documentation is available and current
• Populate and analyze data for the quarterly BOH Divisional Board Report
• Develop, implement and analyze Consumer Satisfaction Surveys and Program Evaluation Studies
• Monitor the provision of services to Identify operational improvements and recommend plans for such
• Create new forms for implementation consistent with operational needs and requirements
• Prepare and update policies and procedures consistent with regulatory requirements

• Client Concerns and Grievances:
  Receive and track client concerns and grievances, investigate when indicated, recommend a course of action, provide a response, and prepare related reports
• Incident Management:
  Maintain communication with the New York State Office of Mental Health, The Justice Center, and/or NIMRS/WSIR regarding all reportable incidents
• Incident Review Committee:
  Prepare the agenda, as well as tracking and trending reports for internal incidents. Facilitate the committee meeting and write-up the minutes
• Special Investigations:
  Conduct investigations under the direction of BOH leadership and/or in coordination with The Justice Center

• Utilization Reviews:
  Audit client case records, prepare findings reports, conduct findings review meetings, and provide follow-up training to staff as needed
• Medicaid Billing:
  Audit documentation for submission, prepare related reports and resolve client issues impacting billing. Work in coordination with the Finance Department around such, as needed
• Audit Preparation:
  Train staff in compliance with audit requirements, conduct environmental assessments, coordinate peer audit reviews, and perform mock licensing and monitoring audits
• Audits:
  Participate in Licensing audits and Monitoring Reviews. Assist in the preparation of Corrective Action Plans as needed

• Maintain and update HIPAA policies and procedures to ensure consistency with requirements for such
• Investigate HIPAA & Compliance related concerns, make notifications as required and prepare reports
• Manage requests for Protected Health Information and prepare responses
• Monitor and evaluate the Corporate Compliance risk areas and develop plans to mitigate such
• Annually draft and update the Compliance Work Plan, including training, monitoring, auditing, and responding to compliance issues
• Update policies and procedures designed to ensure Corporate Compliance
• Participate in training of Board members, staff and contractors regarding Corporate Compliance
• Respond to concerns regarding Corporate Compliance and investigation as directed by agency leadership
• Prepare the Corporate Compliance quarterly reports, facilitate the bi-annual Compliance meetings, and write up meeting minutes for the Divisional and CCCS Board Meetings

• Builds and maintains a comprehensive understanding of laws and regulations for property management
• Reviews and reports on the status of all lease-related documentation to ensure such is current
• Reviews and tracks housing inspection documentation including photographs to promote safe environments and accountability in apartment programs
• Engages in scheduled and unscheduled program visits, including…