Join Buckelew and you will play a pivotal role in making a meaningful impact on the lives of individuals facing mental health and substance use challenges.

Buckelew Programs is the largest provider of behavioral healthcare services in the North Bay for those who would otherwise not have access. We are seeking a new Director of Quality & Compliance to join our team. In this role you will plan and implement systems to ensure compliance with internal and external standards and regulations. You will develop, implement, and participate in quality improvement initiatives; assist in program evaluation and planning consistent with the organizational values and mission; serve as HIPAA Privacy Officer and Compliance Officer.

As part of the Quality and Compliance team, you will work with the Quality and Compliance Manager and the EHR Coordinator and report to the CEO. This position offers a hybrid work schedule with the requirement of working onsite at our corporate office a minimum of two days per week.

RESPONSIBILITIES:

• Serve on the Agency Senior Management Team with other senior staff. Participates in the development and implementation of the strategic plan with goals and strategies for the agency. Develops goals for the quality and compliance department and monitors and reports progress to the CEO.
• Promotes and develops a culture of growth, learning and collaboration across the programs. Coordinates and collaborates with directors of other Agency programs in respect to clinical planning, service delivery, and cross-program issues. Evaluate, revise and manage the agency utilization review of clinical and program services. This includes insuring that the process meets federal and state requirements and that it is designed to improve clinical outcomes.
• Oversee standard compliance as regulated by State of California Title 9 Welfare & Institutions Code, federal MediCal regulations, federal HUD regulations, HIPAA, Community Care Licensing and CARF standards for accreditation.
• In collaboration with Senior Management Team members, develop and use tools which enhance agency quality and compliance. Participate as Senior Management staff member in overall agency planning, budgeting and policy setting and implementing agency decisions as they relate to quality and compliance.
• Provide day-to-day guidance to Senior Management regarding policy and procedures, regulations and confidentiality. Oversee and support Leadership Committees in creating and updating policy and procedure ensuring all policies and procedures are reviewed and updated on an annual basis.
• Facilitate continuous quality improvement (CQI). Develop systems and procedures to monitor conformity to standards and quality improvement using data management and outcomes reporting.
• Monitor monthly chart audits. Clinical program supervisors to complete monthly audits and submit reports to the Quality and Compliance department that indicate number of client charts and number of service providers documenting in those charts (or primary case manager/clinician/service provider responsible for the chart) and outcome of the audit ie. findings needing improvement through training or discipline. Oversee completion of random audits by Quality and Compliance staff in each program at least semi-annually and submit an annual report to senior management. Facilitate program participation in county behavioral health audits as required by county contracts and State Medical Audits and coordinate with program directors to coordinate corrective actions such as staff trainings, improved documentation standards and adherence to regulatory requirements.
• Provide best practice and consultative support services assisting agency staff in reaching adoption/implementation/meaningful use of the electronic health record (EHR) system. Conduct workflow analysis, needs assessments and troubleshoot issues that arise for programs and recommend specific solutions such as installation of alternate methods and procedures, changes in processing methods and practices, or redesign of processes and workflow. Troubleshoot practice management application issues. Serves as administrative interface with EHR vendor. Conduct regular and systematic review of security risk in accordance with the requirements under 45 CFR 164.308(a)(1), implement security updates as necessary, and correct identified security deficiencies as part of risk management process. Responsible for data administration, analysis and management reporting from EHR.
• Coordinate training to improve quality of clinical documentation.
• Oversee the collection of risk data and critical incident reports. Work with senior team members in oversight of operations to ensure agency practice adheres to accreditation and regulatory health and safety standards.
• Serves as organizations HIPAA Privacy Officer including breach reporting. Serve as organizations Compliance Officer which includes: Conducting compliance investigations, keeping CEO apprised of investigations and making recommendations regarding investigations.
• Develop and ensure accurate monthly and annual data reporting including demographics and numbers served.
• Oversight of Records Retention, requests for medical records and Destruction processes.
• Supervision and support of Quality and Compliance Manager.

QUALIFICATIONS:

Education and Experience: Bachelors level degree in social work or related behavioral health field is required, Masters preferred. Additional certifications including e.g. CHPC, CPCO, CCEP, or CHC strongly preferred. Minimum of 5 years experience in a compliance and/or quality management role in a small to mid-size organization, preferably a non-profit. Experience with administrative and program regulations related to county departments governing specific programs, CARF and MediCal standards. Experience in developing data reports in collaboration with data analysts, managers and other program staff. Working knowledge of county, state and federal requirements for utilization review of clinical services; quality improvement tools and processes; and state and federal regulations related to Compliance Programs in healthcare.

Skills and Abilities:

• Self-motivated and able to work independently as well as with a team.
• Candidate must have excellent organizational and administrative skills. Competence with Microsoft Office including Word, Excel, PowerPoint, Access and Outlook at an intermediate level. Experience with electronic health record systems including reporting, preferably in an administrative capacity. Internet skills including the use of online research. Keyboarding skills at 45 WPM or greater, with accuracy.
• Demonstrated planning, analytical and organization skills.
• Proven ability to partner with and support program leaders throughout an organization as well as with government agencies.
• Highly organized and able to effectively prioritize multiple tasks and responsibilities. Reliable, excellent attention to detail and accuracy. Must be able to maintain confidentiality.
• Have and maintain a valid California Drivers License and personal automobile with insurance coverage for use on the job.
• Able to pass Live Scan, Office of Criminal Justice and Department of Social Services clearances.
• Able to work well under pressure, with good judgment and decision-making abilities.
• Working understanding of highly confidential environments and ability to maintain confidentiality.
• Able to effectively lead the quality and compliance department including effective leadership and supervisory skills.

Physical Requirements: Requires occasional lifting (up to 25 pounds), standing, walking, and reaching. Requires frequent hearing and talking. Nearly all work is performed in a comfortable indoor facility. Ability to maintain composure and work quality with some interruptions; regular local travel; involves frequent exposure to demands and pressures from persons other than immediate supervisor. Able to handle objects with both hands and the use of fine motor skills for the duration of a shift. Frequently operates a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer. Vision requirements: Ability to see information in print and/or electronically; possess visual acuity to use computer and other office machinery constantly. Hearing requirements: Ability to hear information in person and by telephone.

BENEFITS: Medical, dental, vision and life and long-term disability insurance, Employee Assistance Program, FSAs, retirement savings plan with company match, eligibility for loan forgiveness, continuing education credits available through our learning management system and generous paid time off policy.

DIVERSITY, EQUITY & INCLUSION: Buckelew Programs values transparency, equity, accountability and inclusion. As a behavioral health organization, we firmly believe that feeling understood, accepted, and supported is essential to mental well-being and promoting recovery; we welcome all people regardless of identities and circumstances. As a thought leader in mental health, substance misuse, suicide prevention, housing equity and community building, we recognize the need to stay current and responsive to diverse communities by bringing different people together to be their authentic selves.

AA/EOE