Job Summary:

The Compliance Coordinator is responsible for compliance for all levels of care for their region. The Compliance Coordinator maintains current knowledge of state requirements, OSHA, Center for Disease Control (CDC), and the Joint Commission for Behavioral Health and other applicable standards. The position also ensures ongoing compliance with Lightfully Policies and Procedures, oversight of Joint Commission and internal audits as related to care by either owning or delegating tasks and/or projects with ultimate accountability for their region. The Compliance coordinator demonstrates the ability to effectively collaborate with other leaders to ensure that required assessments, client and family education, treatment planning, and medical interventions are delivered safely and appropriately for their region. The Compliance Coordinator is proactive in identifying potential risks and provides support mitigating risks and promotes safety for clients and staff.

Major Responsibilities:

• Ensures efficient and safe operations of the facility.
• Actively seeks areas to improve operations for greater compliance and safety for clients and staff.
• Supports in the development of policies and procedures and provides education to staff on them.
• Monitors changes in policies and procedures.
• Ensures compliance binders and postings are in place at each site in the designated territory.
• Works to identify and mitigate all potential risks such as legal, public relations, marketing, billing, clinical, medical, TJC, licensing, etc. and provides recommendations to leaders as appropriate.
• Works closely to support site leaders in preparation of crisis, disaster and emergency preparedness plans.
• Ensures staff mandatory education for their region is completed is completed and documented.
• Ensures full compliance with all federal and state health and safety regulations and requirements including but not limited to:

• Assists with licensure and TJC applications as needed.
• Completes CLIA applications.
• Acts as part of the leadership team for their region, which includes participation in leadership meetings.
• Responsible for the execution of and compliance with policies and procedures, performance improvement, and patient safety, while ensuring the highest quality and HIPAA compliance.
• Acts as leader in client safety by assuring the infection control and environmental safety rounds are completed monthly.
• Conducts investigations and resolves compliance issues.
• Ensures that incident reports concerning client injuries and other incidents are completed so that they can be tracked, trended, and analyzed.
• Serves as a lead for all state surveys and Joint Commission accreditation surveys to ensure excellent results.
• Serves as the point person for their region for all state and Joint Commission agencies.
• Tracks and reports on quality and compliance measures for their region.
• Completes root cause analyses as appropriate for their region.
• Performs annual mock surveys for their region.
• Completes other duties as assigned.

Specific Skills:

• Experience in treatment of mental health disorders and in reviewing, planning, implementing, and evaluating medical services/therapy to individuals with mental health disorders.
• Experience in compliance and quality assurance and working with regulatory and accrediting bodies.

General Skills and Requirements:

• Able to communicate effectively in English, both verbally and in writing.
• Able to work for prolonged periods sitting at a desk and working on a computer
• Able to travel to sites frequently.
• Must have general knowledge of PCs and be proficient in a Windows environment. Requires ability to access and update information in a computer system.

Qualifications:

• Bachelor's Degree required.
• 2+ years of related experience, required.

The pay range for this position is $57,000-$88,500 annually.