General Summary: The Compliance Specialist leads and/or assists the Quality Improvement Director in system wide activities to evaluate and improve adherence to accreditation standards and compliance activities. The Compliance Specialist is responsible for leading and/or participating in quality improvement tasks such as conducting site assessments and mock surveys, maintaining the policy and procedures, fielding questions about policy and procedures, conducting investigations related to program compliance and acting as an internal consultant in matters of accreditation of programs in the organization. JOB RESPONSIBILITIES:Create strategic plan for onboarding all programs for accreditation and continued compliance to standards.Conduct site assessment of compliance to standards using Survey Prep Workbook; use this information to strategically plan areas in need of more focus & assignments.Manage the survey technical work: application, creation of folders/ uploading files in CARF Connect, Drafting survey schedule for survey team and IC staff.Work with sites to complete the QIP post survey and audit for standards cited and other areas as determined.Perform audits on sites for ongoing compliance – developing systems for monitoring fidelity to standards.Work with sites and applicable departments for survey prep and guidance -following plan and established timelines/project management.Meetings post survey to review compliance activities with programs.Work with sites to conduct an annual assessment to standards using the Survey Workbook.Maintain current knowledge of standards and demonstrate ability to train staff in a consultative manner.Assist with EHR template modifications as needed.Assist with policy and procedure reviews and updates and participate in related committees or meetings as needed. Serve as lead for the oversight of the P&P manual, TOC, with crosswalk with standards, regulations, contractual requirements.P&P manual, TOC, with crosswalk with standards, regulations, contractual requirements.Conduct annual HIPAA, Risk, Cultural Competency Assessments.Assist with annual assessment of accessibility plan assessment.Assist with Safety Committee functions and Culture of Safety Program.Participate in health plan, regulatory, accreditation meetings and communicate upcoming changes in processes as applicable.Assist an/or lead process for preparing QI Plan for the Board annually, along with data summary.Serve on CQI Committee and assist with quarterly reports for all sites as needed. Respond to staff/sites with daily questions related to compliance and policies.Assist with, and/or conduct investigations related to compliance complaints and grievances, providing written summaries and maintaining data for trending and process improvement.Review sentinel events, complete mortality review, and participate in mortality reviews as required. Visit sites as needed. Performs other duties as assigned or necessary as they relate to the general nature of the position. QUALIFICATIONS:Education – Master’s degree in related field preferred, or a Bachelor’s Degree and equivalent level of experience.Experience – Minimum 2-years’ experience in quality improvement activities, with a minimum of 1 year experience in accreditation activities. Knowledge and experience in behavioral health preferred. Prior experience with regulatory or health plan requirements preferred.REGULATORY:Minimum 21 years of age.DPS Level I fingerprint clearance (must possess upon hire and maintain throughout employment).CPR, First Aid, AED certification, if required (must possess upon hire and maintain throughout employment).Current, valid Driver’s License and 39-month Motor Vehicle Report and proof of vehicle registration liability insurance to meet insurance requirements, if required.Initial current negative TB test result, if required (Employer provides).Questions about this position? Contact us at HR@ichd.net.