Director of Compliance (Quality Improvement)

Overview

Under the direction of the Senior Director of Quality, this position is accountable and responsible for designing and implementing systems to ensure a state of continual regulatory, licensure and accreditation compliance as well as oversight of patient safety programs and risk management. This individual will provide specific support and coordination for the agency during regulatory visits and surveys. This position supports the accreditation preparation process for the organization, including managing all mock surveys and internal audits, as well as maintaining the organization’s communication regarding changes and updates for regulatory compliance.  

What You'll Do

• Trains and coaches’ staff, sets clear expectations, monitors outcomes, creates a culture of open communication and helps team members solve complex problems through individual supervision and team meetings. Fosters a collaborative, supportive and collegial environment across departments.
• Reviews, interprets and assists various departments, leadership and staff in the implementation of applicable federal, state and local regulations as well as Joint Commission and HRSA standards and requirements. 
• Leads all on site regulatory, licensure and accreditation surveys including but not limited to: Joint Commission, HRSA, OSHA, and MDH. Lead collaboration efforts with management, clinical staff and administration with information regarding current accreditation status and survey process. Provides input on service or process design to assure regulatory compliance. 
• Oversees license and certification requirements for the health center including Behavioral Health licenses, CLIA, ORP and additional certification requirements as required by the health center
• Maintain a continual state of readiness through proactively assessing the health care environment and collaborate with health center staff to maintain a safe environment to support high-quality patient care.

• Develop, identify and conduct training for staff and leadership regarding compliance-related needs including the regulatory process, key regulatory needs (e.g. HIPAA), and annual training requirements for health center staff.
• Responsible for managing the process to ensure that policies and procedures are accurate and reflective of regulatory compliance and funder requirements. Develop and monitor review cycles, assisting management when changes are needed.
• Organizes and conducts internal audit process to measure regulatory compliance and ensure patient safety standards are being met (e.g. mock surveys, tracer activities and site visits). Collaborate with the facilities department to ensure drills, tabletops, and other preparedness activities are being completed. 
• Manages the incident resolution process and system, including the completion of root cause analyses, implementation of corrective actions and communication to key stakeholders. Co-chairs and supports the Conduct Action Plan (CAP) committee in conjunction with the Director of Community Relations and Engagement to ensure client, staff and agency safety.
• Manage and develop Patient Safety, Infection Prevention and Control Program in coordination with the Medical, Operations and Behavioral Health leadership, Director of Dental, and Director of Facilities and Security. Serves as the Infection Control Lead ensuring compliance with applicable standards and regulations including respiratory protections, hand hygiene, and guiding the infection prevention and control activities of the Agency. Chairs the infection prevention and control workgroup and collaborates across sites to ensure Agency practices are reducing infection risks to staff and clients.
• In collaboration with the Senior Director of Quality, oversees the risk management planning and activities to reduce risks to the health center and collaborate with executive leadership to respond to and mitigate risks. Oversee risk assessments and annual risk management plan. Identifies and assesses quality and risk information to collaborate and prepare corrective action plans for health center compliance. Tracks and trends regulatory compliance issues and identifies resources to correct deviations from regulation. Serves as the risk manager for the organization.
• Serves as staff to the Compliance and Risk Management Committee of the Board of Directors, as well as relevant staff committees.

Key Agency Responsibilities  

In addition to role responsibilities, each staff member of Health Care for the Homeless has the following responsibilities as a part of their employment: 

• Models and reinforces the Health Care for the Homeless “core values” of dignity, authenticity, hope, justice, passion and balance
• Actively participates in performance improvement activities and actively participates in advocacy activities that support the mission of HCH
• Performs other duties on an as-needed basis
• Protects our client’s personal health information by maintaining compliance with HIPAA and other relevant Health Care related IT security regulations

Why Join Us?

• Be part of a mission-driven team committed to racial equity, social justice, and community wellness.

• Work in a dynamic, people-first organization that centers compassion, authenticity, and hope.

• Receive training and support to grow in your advocacy and peer work.

• Help shape the future of housing and recovery services in Baltimore.

Read more about our clients and the people we serve here: https://www.hchmd.org/who-we-help

Join us in advancing health equity and delivering exceptional care to our community’s most underserved populations. Apply today to be a part of something bigger.

Health Care for the Homeless is an equal opportunity employer.

Notice to Applicants
Health Care for the Homeless participates in E-Verify. All newly hired employees are required to complete the I-9 Employment Eligibility Verification form and provide documentation proving their identity and legal authorization to work in the United States.

We use the E-Verify system to confirm employment eligibility in accordance with federal law.