Compliance Specialist, Healthcare

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:

Incident Reports 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.

Satisfaction Surveys 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.

Client Rights Officer 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.

New Hire Orientations/Annual Trainings Conduct compliance training with personnel at hire and annually either in person or by an approved electronic or software platform.

Policies and Procedures 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

Community Meetings Attend and summarize community meeting minutes with action items, as applicable.

Disseminate information to TCN leaders and employees, as applicable.

Focus Reviews 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.

Observations…