St. Joseph's Addiction Treatment and Recovery Centers

Location: Hybrid / Inpatient Facility - Saranac Lake, NY

Position: Full-time Associate Director of Quality Assurance and Corporate Compliance

Schedule: Monday through Friday, 8:00am to 4:30pm 

Pay Range: $50,000.00/year to $65,000.00/year

Summary/Objective:

The Associate Director will directly oversee the Incident Management and Quality Assurance Specialists. They will be responsible for the overall monitoring and compliance of agency-wide incident management system, internal and external audits, and compliance to all pertinent regulations.

Required Education and Experience:

• Bachelor’s degree from an accredited institution preferred.
• 3-5 years’ work experience in related field.
• Knowledge of NYS mental hygiene agencies’ regulations and certification procedures preferred.

Travel: Frequent travel required. 

Essential Functions (Job Duties):

Enforce Corporate Compliance Plan:

• Complete and oversee necessary Corporate Compliance audits of all assigned programs and departments within St. Joseph’s.
• Assist Program Directors with plans of corrective action for external audits.
• Assist programs and departments with writing and implementing policies and procedure to ensure compliance with regulations.
• Assist the Corporate Compliance and HIPAA privacy officer in the implementation of St. Joseph’s corporate compliance plan.
• Works closely with Senior Director of Compliance, Director of Corporate Compliance and Quality Assurance, Quality Assurance Specialists, Human Resources, and any other departments as needed or as requested.
• Assist Senior Director of Compliance and Director of Corporate Compliance and Quality Assurance by representing Compliance at meetings as needed, speaking on behalf of the Compliance department, and filling in if the Senior Director and/or Director of Corporate Compliance and Quality Assurance is off.

Incident Investigation and Reporting:

• Adheres to and supports agency policy and procedures for incident management.
• Oversees all internal and external investigation.
• Conducts internal investigations as needed: Collect and review evidence and documentation; Interview witnesses; Review policies and procedures; Analyze factual findings; Complete written investigation reports; Provide clinical and administrative recommendations.
• Oversee and monitor appropriate follow up to all corrective actions and program responses.
• Demonstrates the ability to navigate and submit information into IRMA, NIMRS, and WSIR within regulatory time frames.
• Prepare material for and co-chair the monthly incident review committee.
• Monitor and maintain incident reporting database.
• Assists in the development of reports and statistical information related to incident management trends for the agency.
• Ability to establish a functional working relationship and work productively with staff within the agency and outside entities.
• Serve as a liaison and coordinate investigative activities with investigators and law enforcement officers from various agencies.

Implement Quality Assurance (QA) Plans:

• Perform and oversee QA surveys to ensure programs meet the quality expectations of St. Joseph’s and all pertinent regulatory agencies.
• Assists in the collection, tracking and reporting on key performance indicators/quality in service delivery
• Assist Program Directors with plans of corrective action for all audits by helping to manage the process of completion as mentioned above.

Report Audit and Survey Findings:

• Compile monthly summary of audit and survey findings/recommendations
• Assist in the creation, revision, and updating of internal audit protocols under the direction of the Director of Corporate Compliance and Quality Assurance.

Assist in Development of New Programs:

• Work with program and administrative group to ensure new or proposed programs comply with all pertinent regulatory agencies.

Stay Current on Regulations and Standards:

• Maintain a working knowledge of relevant issues, laws and regulations through websites, email list serves, training programs and peer contact.
• Seek inter and intra agency trainings, webinars, and conferences to improve knowledge and skills.

Policy and contracts Oversight:

• Assist Director of Corporate Compliance and Quality Assurance with responsibility of collecting, updating, storing, and maintaining agency policies and contracts; manage policy and contract library.
• Monitor regulation and licensing changes and coordinate policy updates and reviews in response to a fluid regulatory environment.

Administration:

• Provide supervisory oversight of all reports involving assigned staff including, but not limited to; performance evaluations, PTO approvals, scheduling, etc.

Competencies:

• Strong Communication Skills
• Ability to handle sensitive and challenging situations
• Tact and Discretion
• Attention to detail
• Collaboration
• Trustworthiness and Ethics
• Confidentiality
• Organizational Skills
• IT Proficiency