Compliance Specialist

Tcn Behavioral Health Services Inc; Xenia (OH); On-site; USD 65,000 - 93,000; Full time

Job summary

TCN Behavioral Health Services Inc in Ohio seeks a Compliance Director to oversee regulatory adherence and funding requirements for state, federal, and local funds in behavioral health services.

The role emphasizes incident reporting, client rights, policy review, and CQI-driven improvements, ensuring data integrity and uninterrupted service delivery while satisfying regulatory mandates and organizational standards.

Qualifications

• Associates degree with licensure in behavioral health field preferred.
• Three years in behavioral health and leadership experience preferred.
• Three years in quality assurance/quality improvement activities required.
• Knowledge of safety rules and procedures.
• Strong analytical and problem-solving skills.
• Excellent interpersonal and communication abilities.

Responsibilities

• Oversee the incident report process including training staff on filing and submitting incident reports, ensuring incident reports are entered completely and accurately.
• Review incident reports regarding safety in monthly safety committee meetings.
• Annual review of all incident reports with CQI committee to develop a plan of action.
• Coordinate death review meeting and take notes when required.
• Maintain documentation within electronic document management systems.
• Maintain, create, or redesign satisfaction surveys and analyze results.
• Receive, address, research, document and maintain all client grievances and report to committees/boards.
• Conduct Client Rights training for new personnel and annual trainings.
• Lead the annual review and update of policies and procedures.
• Attend and summarize community meeting minutes with action items.
• Conduct focus reviews for new clinical staff and chart reviews.
• Complete observations of all clinical providers at least every 6 months and summarize findings.
• Oversee additional session requests and chart reviews as needed.

Skills

Analytical skills

Problem-solving

Interpersonal skills

Attention to detail

Active listening

Leadership

Education

Associates degree with licensure in behavioral health field

Job description

Position Summary:This position holds shared responsibilities for overseeing and managing duties associated with maintaining the organization’s compliance with regulations, standards, and procedures pertinent to the receipt of federal, state, and local funds. Focused on the provision of behavioral health services, the role entails meticulous attention to detail and adherence to regulatory frameworks. Additionally, the position involves collaborating with relevant stakeholders to uphold the highest standards of service delivery while aligning with funding mandates and guidelines.Key Responsibilities:Incident ReportsOversee the incident report process including training staff on filing and submitting incident reports, ensuring incident reports are entered completely and accurately, forwarding to all applicable staff for signatures, and reporting to the Ohio Department of Behavioral Health (Ohio DBH) as required.Review incident reports regarding safety in monthly safety committee meetings.Conduct an annual review of all incident reports to identify areas of concern and work with members of the CQI committee to develop a plan of action to address any areas of concern.If the incident involves a client death, request a coroner’s report, and review the case with the Chief Medical Officer to determine if a death review is necessary.If required, coordinate the death review meeting, and take notes during the meeting.Maintain documentation within the designated electronic document management systems.Satisfaction SurveysMaintain, create, or redesign (as needed) satisfaction surveys distributed to clients and community partners/referral sources.Initiate targeted survey distribution periods at least bi-annually for client satisfaction surveys, and ongoing or as needed for community partners/referral sources.Enter paper survey responses or work with other identified staff to ensure proper data entry.Analyze/Review results and compile a report regarding findings.Share survey results with administration and department managers, as applicable.Review survey results and findings in monthly PI/CQI meetings.Develop a report regarding responses and plans to address areas of concerns from the survey results in collaboration with department managers.Client Rights OfficerReceive, address, research, document and maintain all client or parent/guardian written or verbal grievance(s).Monitor and evaluate all Client Rights and Grievances policies and procedures.Report all grievances to appropriate Committee, CEO, Licensing/Credentialing Boards, and Human Resources Department, if applicable.Report all grievances to the MHRB on a monthly basis or as requested; and to TCN’s Board of Directors quarterly as directed.Conduct Client Rights training to all new personnel during orientation and current staff on an annual basis.New Hire Orientations/Annual TrainingsConduct compliance training with personnel at hire and annually either in person or by an approved electronic or software platform.Policies and ProceduresParticipate in the annual review and update (as needed) of TCN Behavioral Health Services’ policies and procedures.This may require being the lead on forming and managing meetings or committees during the review processCommunity MeetingsAttend and summarize community meeting minutes with action items, as applicable.Disseminate information to TCN leaders and employees, as applicable.Focus ReviewsWithin the first 30 days of a new clinical employee’s date of hire, conduct 2 clinical chart reviews (focus reviews).Conduct an additional chart review (focus review) 60 days after a new clinical employee’s date of hire.Conduct clinical chart reviews (focus reviews) on a minimum of 2 charts a week.ObservationsComplete observations on all clinical providers at least once every 6 months, including reviewing any documentation conducted during the observation.Write up a review/summary of the observation for the provider and supervisor to review.Additional Session RequestsOversee Additional Session Requests Procedure in the adult mental health department, as needed.Conduct a chart review when a provider submits a request for additional sessions.Within the review, ascertain the viability of the additional sessions request and propose alternative treatment recommendations where appropriate.Maintain all reviews within the designated electronic document management systems.When returned, ensure corrections are made to any areas of concern identified in the review.Run a report monthly regarding clients that are approaching or over 12 sessions to ensure providers are following the model and making requests, as needed.GeneralAssists with on-site surveys and other duties as needed or requested by the Corporate Compliance Officer.Maintains license or registration appropriate to profession and/or appropriate to job requirement, including appropriate amount of continuing education at all times of employment.Maintains agency-required annual training including client rights and grievances, safety training, infection control, and others as required by Ohio DBH, CARF, and/or other regulatory entities. .Remains free from citations by other providers or by consumers for unethical practice and meets standards for own profession.Other job duties as assigned.Adheres to all organizational and departmental policies, complying with all behavioral and ethical expectations.Completes all agency-required trainings, including but not limited to client rights and grievances, safety training, infection control, etc.Demonstrates and supports the company core values TCN C.A.R.E.S. “Commitment, Accountability, Respect, Empathy, Service”Minimum Qualifications:Education: Associates degree with licensure in behavioral health related field preferred.Experience: Three years in behavioral health and leadership experience preferred; three years in quality assurance/quality improvement activities required.Certification: N/A.Other: N/A.Knowledge, Skills, & Abilities:Knowledge of: Safety rules and procedures, Agency policy and procedures, Regulatory Agency requirements, Documentation requirements.Skills.Sound analytical skillsStrong problem-solving skills.Strong interpersonal skills.Capacity to perform duties effectively under potential emotional stress and conflict situations.Proficiency in utilizing basic computer skills and office equipment for documentation and communication purposes.Practice of a client-focused approach, demonstrating active listening skills, reading comprehension, critical thinking, and leadership abilities.Abilities:Multi-tasking.Seeing, hearing, and communicating information clearly.Demonstrating strong attention to detail.Following directions.Use of computer keyboard.Sitting for periods of time.Lifting up to 25 pounds.