Quality, Compliance and Accreditation Manager

Delphi Technologies; Hamilton Township (NJ); On-site; USD 75,000 - 89,000; Full time

Job summary

Catholic Charities, Diocese of Trenton is seeking a Quality, Compliance and Accreditation Manager to support quality improvement, compliance, accreditation, and risk management activities. The role requires collaboration with leadership and program staff to promote process improvement, safety, and regulatory readiness across the organization.

Responsibilities include audits, data analysis, policy development, and liaison with licensing bodies.

Qualifications

• Bachelor’s degree in healthcare administration, Nursing, Social Work, Psychology, Public Health or related field.
• Master's degree preferred.

Responsibilities

• Coordinate quality improvement, compliance, accreditation, and risk management activities.
• Conduct scheduled and unannounced case record audits for compliance with Joint Commission, state licensing, payer, and organizational standards.
• Conduct facility and environmental compliance rounds assessing Environment of Care, Infection Control, Medication Management, Life Safety, and National Patient Safety Goals.
• Coordinate Joint Commission survey readiness, mock surveys, tracers, and evidence collection with leadership and program staff.
• Collect, analyze, trend, and report quality and compliance data.
• Serve as a liaison for licensing inspections, payer audits, and other regulatory reviews as assigned.
• Coordinate survey logistics, documentation, and responses, and escort surveyors during site visits.
• Participate in and/or chair Quality Improvement, Safety, Infection Control, and other assigned committees.
• Prepare committee agendas, minutes, reports, and monitor follow-up activities.
• Coordinate development, review, revision, implementation, and communication of policies and procedures.
• Serve as Quality Improvement representative for assigned programs.
• Develop audit tools, dashboards, scorecards, and monitoring systems.
• Assist with Plans of Correction and performance improvement initiatives across the organization.
• Monitor completion and effectiveness of corrective actions.
• Review incidents, sentinel events, and risk data; investigate and complete Root Cause Analyses.
• Provide education regarding regulatory and accreditation standards and documentation requirements.
• Monitor regulatory and accreditation changes and communicate updates.
• Collaborate with program staff, operational and clinical leadership to improve quality and compliance.
• Perform other duties as assigned.

Skills

Analytical skills

Organizational skills

Communication skills

Project management

Education

Bachelor’s degree in healthcare administration, nursing, social work, psychology, public health or related field

Master’s degree preferred

Tools

Microsoft Office

Electronic Health Records (EHR)

Job description

Quality, Compliance and Accreditation Manager

About the Organization Catholic Charities, Diocese of Trenton is a faith inspired non-profit organization, mission-driven, family-friendly, and passionate about services to our communities. We offer a wide variety of exciting career opportunities in the areas of Direct Care, Clinical, Fundraising, Human Resources, IT, Finance, Marketing, and Nursing. When you join us, you can expect a true focus on work-life balance, rewarding career, competitive salaries, and comprehensive benefit programs. Some of our benefits include: generous paid holidays, vacation, and sick time; Employee Assistance Program, excellent health & pension plans; Public Student Loan Forgiveness program; and wide array of training and staff development opportunities to earn on-site CEUs. Catholic Charities is an Aff…

To learn more about the agency, please visit our website at: www.catholiccharitiestrenton.org. For frequently asked questions, please click here: https://www.catholiccharitiestrenton.org/careers/frequently-asked-questions/

Req Number ADM-26-00003

Location CAS - Access Center (Hamilton, NJ)

Full-Time/Part-Time Full-Time

Number of Openings 1

Category Administration

JOB SUMMARY

The Quality, Compliance and Accreditation Manager supports the organization's Quality Improvement, Compliance, Accreditation, and Risk Management activities. Working collaboratively with leadership and program staff, the Manager promotes continuous quality improvement, regulatory compliance, safety, and organizational excellence. Responsibilities include case record reviews, facility and environmental compliance audits, Joint Commission survey readiness, performance improvement initiatives, data analysis, corrective action monitoring, and support for state licensing, payer, and accreditation requirements.

ESSENTIAL FUNCTIONS

• Coordinate quality improvement, compliance, accreditation, and risk management activities
• Conduct scheduled and unannounced case record audits for compliance with Joint Commission, state licensing, payer, and organizational standards.
• Conduct facility and environmental compliance rounds assessing Environment of Care, Infection Control, Medication Management, Life Safety, and National Patient Safety Goals.
• In collaboration with the Director of Quality Improvement and Compliance, coordinate Joint Commission survey readiness, mock surveys, tracers, and evidence collection.
• Collect, analyze, trend, and report quality and compliance data.
• Serve as a liaison for licensing inspections, payer audits, and other regulatory reviews as assigned.
• Coordinate survey logistics, documentation, and responses, and escort surveyors during site visits.
• Participate in and/or chair Quality Improvement, Safety, Infection Control, and other assigned committees.
• Prepare committee agendas, minutes, reports, and monitor follow-up activities.
• Coordinate the development, review, revision, implementation, and communication of policies and procedures.
• Serve as Quality Improvement representative for assigned programs.
• Develop audit tools, dashboards, scorecards, and monitoring systems.
• Assist with Plans of Correction and performance improvement initiatives across the organization.
• Monitor completion and effectiveness of corrective actions.
• Review incidents, sentinel events, and risk data; investigate and complete Root Cause Analyses.
• Provide education regarding regulatory and accreditation standards and documentation requirements.
• Monitor regulatory and accreditation changes and communicate updates.
• Collaborate with program staff, operational and clinical leadership to improve quality and compliance.
• Perform other duties as assigned.

POSITION REQUIREMENTS

KNOWLEDGE/SKILLS/ABILITIES (Competencies)

• Experience conducting clinical documentation reviews and quality audits.
• Knowledge of Joint Commission Behavioral Health standards.
• Knowledge of behavioral health regulations, HIPAA, CMS, and state licensing requirements.
• Strong analytical, organizational, communication, and project management skills.
• Ability to interpret regulations and implement quality improvement initiatives.
• Proficiency with Microsoft Office suite and electronic health record systems.

MINIMUM QUALIFICATIONS

• Bachelor’s degree in healthcare administration, Nursing, Social Work, Psychology, Public Health or related field required.
• Master's degree preferred.
• Minimum five years of progressively responsible experience in behavioral health quality improvement, compliance, accreditation, or healthcare operations.

WORK ENVIRONMENT / PHYSICAL REQUIREMENTS

Frequent travel between agency locations. Combination of office, residential, and community settings. Requires walking facilities during audits, use of computers, and a valid driver's license.

Exempt/Non-Exempt Exempt

Weekly Work Hours 40

Proposed Salary $75,000

Schedule Monday-Friday, 9:00am-5:00pm; Some flexibility required-- occasional evenings to meet program needs

This position is currently accepting applications.