Sr. Director of Corporate Compliance

Sr. Director of Corporate Compliance

Role Description

General Statement of Job

This position is responsible for ensuring regulatory compliance, improving clinical outcomes, data integrity, risk mitigation, audit oversight, performance analytics, process redesign, staff education support, and continuous organizational improvement. This role develops and publishes data-driven program improvement expectations as designated by the Executive Leadership Team, in collaboration with Clinical and People Development Teams. This role also provides or coordinates much of the staff training necessary to achieve the desired level of outcomes, and ensures the organization.

Job Classification:     Salaried Exempt

Reports to:                 President & CEO

Supervises:                QA/QI Coordinator

Minimum Training and Experience

Must possess excellent oral and written communication skills. Experience with training programs in a residential environment for individuals living with intellectual disabilities and complex healthcare acuity is a plus. This role will be expected to employ a wide range of knowledge, resourcefulness, and creativity. It is understood that training and monitoring outcomes is critical for all shifts, thus this role will be required to have a presence during all shifts. 

Minimal qualifications:

·      Education and experience that would facilitate status as a Qualified Professional,

·      or a Registered Nurse with an active North Carolina License, or the ability to achieve a North Carolina

RN License.

Experience

• Minimum of 5 years experience providing leadership to Continuous Quality Improvement initiatives, including clinical audit leadership roles, or
• Minimum of 5 years nurse leadership or clinical operations experience (preferably IDD, pediatrics, behavioral health, rehabilitation or geriatric post-acute care).
• Strong knowledge of CMS survey process, audit design, regulatory interpretation, clinical compliance, data analytics, trends, Performance Improvement Plan execution, and process design and redesign.
• Expertise in clinical documentation standards and incident reporting accuracy.
• Ability to analyze clinical and operational data with systems-level planning.
• Ability to lead interdisciplinary quality committees.
• Ability to conduct compliance related investigation procedures.

Essential Duties & Responsibilities

# Maintains regular contact with the Horizons team to support regulatory compliance on a 24 hour

basis.

# Develops and manages a QA/QI Plan that reflects the high quality of care expected by Horizons as well

as all applicable rules, regulations, policies, procedures, and laws. The plan also describes the process

(training, documentation) by which the standards will be achieved and monitored.

# Coordinate interdisciplinary performance improvement committees including nursing, CNA, DSP,

rehabilitation therapy, dietary, behavioral health, and operations, including quarterly facilitation of

benchmarks data to Leadership.

# Develops and maintains ICF survey outcomes tracking system.

# Develops and maintains CARF Accreditation standards to operate the Respite program.

# Collaborate with Sr. Director of Clinical Services to ensure corporate competence in clinical process

design and redesign, including:

• Pressure injury and infection protocols and compliance tracking as it pertains to resident repositioning requirements
• Fall risk and trend analysis as it relates to resident lifting and transfer
• Hospital admission and readmission analytics
• Behavioral incident patterns
• Ancillary therapies progress
• Survey Readiness Leadership

# Evaluates current policies and training procedures, and provides observations and recommendations to

the organization, to make improvements which lead to the highest quality of service delivery and to

ensure the health and safety of the residents.

# Collaborates with the QPs to ensure all-staff training is provided in accordance with the goals of resident

interdisciplinary planning.

# Provides consultation to the Clinicians, Team Leads, QIDPs, and DSPs to ensure programs and services

are implemented in accordance with QA/QI strategies.

# Collaborate with the Sr. Directors of Clinical Services and People Developmental to ensure policies and

procedures are monitored and updated to include regulatory changes.

# Design, execute, and oversee robust audit systems to support compliance with regulatory requirements.

# Analyze audit data from internal audits and regulatory trends to recommend and monitor improvement

initiatives.

# Demonstrates appropriate application of rules, regulations, policies, and procedures in all training and

interaction with staff.

# Maintain records and trends for Data-Driven Outcomes and provides QA/QI Plan training during New

Employee on-boarding, and during regularly scheduled staff training and refresher sessions.

# Collaborates with the Sr. Directors of Clinical Services and People Development, QIDPs, and Team Leads

to ensure documentation is accurate and meets established regulatory benchmarks

# Provides staff training data to the Office of People Development for inclusion in the personnel files.

# Supports the Sr. Director of Clinical Services in systematic tracking, trending, and reporting of adverse

events including falls, infections, medication errors, restraint use, pressure injuries, G-tube

complications, abuse/neglect allegations, and hospital transfers.

# Identifies and compiles the data needed to demonstrate the achievement of the goals of the QAQI Plan

and, if needed, provides a report to the MCOs or others as requested.

# Reviews and tacks all incident reports for systemic problems and develops training to address problems

and reduce the number and types of incidents.

# Shares quarterly QA/QI plan updates with the organization, including the President & CEO for inclusion

of the Board of Directors.

# Engages in practices that ensure their own continuous learning, including familiarity with policies and

procedures, reviewing of regulations, and attendance at seminars and conferences

# Demonstrates knowledge of technology and software used by Horizons in providing services to the

residents and is able to train staff in the use of computers and software.

# Participates on the Executive Leadership Team, including participating in the after-hours and weekend

on-call rotation.

# Performs other duties as assigned.