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|Job Category :
||Colorado Springs, CO
|Job Description :
||Position: Compliance ManagerLocation: Colorado Springs, ColoradoReports to: Executive DirectorSchedule: Monday to Friday 8:00am to 4:30pmCompensation: $55.000-58,000 Annual Salary + Full Time BenefitsMedical, Dental, Vision | Short/Long Term Disability and Life Insurance401k Program with up to a 5% Match4 weeks paid days off per calendar year (combination of PTO and Paid Floating Holidays)A collaborative and supportive community of therapists and team membersA company culture that prioritizes diversity, inclusion and equity for clients and staffPersonal and Professional growth opportunitiesPosition Overview: * In combination with other team members, the Compliance Manager supports the admissions, clinical, medical and operations teams with a variety of tasks, including Joint Commission compliance administrative support, maintenance & facilities oversight, recruiting supports, etc.Education: High School Degree or GED is required, Bachelors or Masters Degree in a Behavioral Health Science (clinical social work, clinical psychology, marriage and family therapy, or a related field) or in Education is preferredTraining & Experience: Experience working in a high pace environment requiring attention to detail requiredExperience in healthcare compliance and/or regulatory audits preferredHands on maintenance experience preferredPrevious experience with substance abuse treatment is preferred; preferred experience with a treatment facility in the detox, residential, partial hospitalization (“PHP”), and/or intensive outpatient (“IOP) settingDUTIES & RESPONSIBILITIES OF THE POSITION: Contribute to a high-performing culture, focused on partnering with clients as we inspire and empower changeCollecting and organizing data and required follow up with the team to ensure compliance with JCAHO standardsServes as the in-house expert on Joint Commission requiring in-depth knowledge of Behavioral Health accreditation standardsResponsible for managing the agency Joint Commission extranet page, including, but not limited to: annual application submission; annual ICM submission; initiating the use of Joint Commission resources on the extranet, ongoing communication with Joint Commission Standards Interpretation Group (SIG) as necessary and serves as the liaison between the Company and the Joint CommissionAssists programs in auditing and monitoring processes to ensure that appropriate standards are in place and are being implemented effectivelyCoordinates with Leadership Team to address and resolve operational issues as they arise using quality improvement practices and data driven problem solving methods to improve, develop and maintain systems and procedures. This includes the implementation of a robust monitoring system as well as data collection system for ongoing performance oversight of all Joint Commission standardsAssists in developing and overseeing action plans to prepare for surveys. This includes assisting in the development and administration of a constant survey readiness infrastructure that assesses compliance with accreditation standards on an ongoing basis. Recommends to Leadership Team an implementation plan of activities to improve performance and increase standardization of like processesResponsible for developing a formal response to Requirements for Improvement findings as a result of the accreditation survey process. Additionally, responsible for leading performance improvement activities related to noncompliance identified during the annual ICM results.Assists in developing and conducting training and education related to Joint Commission standards.Assists in drafting, reviewing and/or revising policies/procedures, service delivery documentation, outcome tracking, etc. to maintain standards compliance.Assists in the preparation of monthly reports to be reviewed at the Performance Improvement (PI) meetings regarding Quality and Safety standards compliance within each program as well as updates on the status of any Plans of Correction.Responsible for monitoring changes to Joint Commission standards and communicating to all relevant Leadership and Program staff. Additionally, assists in the evaluation and modification of current systems to reflect compliance with new standards within the timeframe designated by The Joint Commission.Utilize problem-solving techniques to identify solutions to problems and implement strategies resulting in increased compliance. This will include coordination with various administrative departments to ensure that standards and operations are aligned.Required to travel across the entire agency network as necessary to provide support to program and clinic staff to address identified issues.Complete core curriculum training(s) and all other required trainings, specific to this position.Responsible for assisting in the oversight of the development, implementation, maintenance, and monitoring of all processes and control systems related to achieving and maintaining Joint Commission standards complianceSupport maintenance needs and overall facility oversightScheduling and administrative support for the management teamHands-on computer skills including Word, Excel and OutlookMust possess a current valid driver’s license and a satisfactory Motor Vehicle ReportMust successfully pass a criminal background check and drug screeningAdhere to all aspects of the clinical program’s policies and procedures to ensure quality performance and assist the team with any quality improvements that may be necessaryParticipate in weekly team meetingsParticipates in the facility-wide Performance Improvement ProgramOther duties as assignedJob Type: Full-time
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