St. Anne Institute

Job Description

I.                                                          TITLE:                                   Assistant Director – Quality Management & Compliance

II.        SUPERVISOR:                     Director – Quality Management & Compliance

III.      HOURS PER WEEK:          35 hours (EXEMPT)

IV.       QUALIFICATIONS:

• Master’s degree preferred.  Minimum requirement is a bachelor’s degree in Human Services field, Human Resources or Business Administration,

• Minimum of 5 years experience working in administration, regulatory standards, and regulations

• Excellent organizational, computer and leadership skills

V.                                                        FUNCTIONS:                       

            Continuous Quality Improvement:

• Provide leadership and guidance to the Quality Management Specialists throughout the agency, specifically in the agency’s Community Clinical and Care Management Division, in the advancement of the agency’s Continuous Quality Improvement Program.  
• Work collaboratively with the Director of Quality Management and Compliance, and all staff in the development of agency policies and procedures and ensure that the agency’s Policy and Procedure Manual and Personnel Manual is organized and updated as required. 
• Assist in leading the agency’s Risk Management activities including, but not limited to, the Quarterly Target Reviews, Incident Committee, etc. 
• Facilitate the distribution of agency’s Quality Management Plan to stakeholders.
• Support the ongoing evaluation of the agency’s Electronic Health Record (EHR) and make improvements as necessary.  
• Assist in the creation and administering of the annual Staff and Client Satisfaction Report identifying performance trends based on the analysis of data from the Satisfaction Surveys.  Data from the Exit Interviews may also be utilized for said reports.  
• Collaborate with the Human Resources department to track the status of annual performance evaluations, NYS Justice Center Code of Conduct, annual Harassment Policy acknowledgment, training attendance, etc. 
• Input agency incident reports into the New York State Justice Center for the Protection of People with Special Needs’ Administrative Action Reporting Mechanism (AARM) database, as requested.
• Train and supervise the QM Interns and coordinate their job assignments.
• Assist, when necessary, with liaising with the NYS Justice Center, NYSOCFS and NYSED in gathering incident information, scheduling interviews with staff and students, and completing the Corrective Action Plans (CAP).  
• Assist the program leadership in accessing the agency camera system to search for and record video, as requested.
• Assist in the provision of Quality Management Orientation to all staff.
• Coordinate all aspects of program audits, reviews, etc. and ensure compliance with Council on Accreditation, NYS Justice Center for the Protection of People with Special Needs, NYS Office of Children and Family Service, NYS Education Department, NYS Department of Health, and NYS Office of Mental Health standards, regulations, and laws. 
• Attend and take notes at the daily Risk Management meeting in the absence of the Director of Quality Management and Compliance, as requested.

Council on Accreditation:

• Organize all policies, procedures, reports, and other documents required by the Council on Accreditation for the self-study and site visit.
• Develop, edit, and modify external surveys, reviews, and questionnaires to meet Council on Accreditation standards and other applicable laws and regulations.
• Review and track changes in Council on Accreditation standards; distribute standards to agency administrators as required/requested.
• Answer general questions and clarify standards, procedures, and requirements to QM Committee members.
• Monitor the status of all reports, documentation, evaluations, surveys, and other information required for agency compliance with the Council on Accreditation and other regulatory agencies.
• Coordinate and facilitate primary tasks associated with Council on Accreditation activities.
• Update Maintenance of Organization Plan for Council on Accreditation

Training & Staff Development:

• Provide AWARDS Electronic Health Record (EHR) training to staff across agency programs.
• Assist in the delivery of Code of Conduct, Harassment, Mandated Reporter, Confidentiality and Article 29-I training to staff across agency programs.

Billing:

• Develop, implement, and maintain a system of communication with the SAI Business Office (Billing, Contracts and Accounts Receivable) for billing of contracts, programs, and third-party insurance providers. 
• Assist supervisory staff and the SAI Business Office (Billing, Contracts and Accounts Receivable) with monthly agency/contract billing.
• Track and collect client co-payments including self-pay or sliding scale fees.
• Coordinate the activities of Private Insurers to ensure the following:

• Contact is made with the Private Insurance companies and clients to assist with the following:
• Enrollment, disenrollment, and transition information
• Securing identification showing the effective enrollment date, including immediate temporary identification
• Collaboration with clinical, billing and an array of service providers and referral partners
• Eligibility for public or private health insurance
• Coordination of benefits
• Provide continuous confirmation and/or facilitation of the insurance enrollment.

• Develop, implement, and maintain a system of communication and notification among Private Insurance companies, the client and referring partners that includes mechanisms for sending and receiving information, including new enrollment and disenrollment.

General:

• As a member of the agency’s Quality Management Team serve as the agency’s “Gatekeeper” for all information flowing into and out of the agency.
• Maintain/update Initial Service Plan/Intake and Caseload Data documents.
• Edit and approve designated employees’ timesheets in the Kronos timeclock system.
• Work in tandem with the agency’s Development Dept. in updating the Agency Bulletin Board and website, and post program/client information to the SAI social media sites on an as needed basis. 
• Abide by the NYS Justice Center and the SAI Codes of Conduct/Ethics
• Complete administrative duties at the request of the Chief Executive Officer

Employee Signature:                                                                                                                          Date:                                      

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