Deliverables/Principal Results Expected: • Work in collaboration with Clinical Directors/Supervisors, Executive Directors, VP of Operations, Assistant VP of Operations, and the quality team to work as a unite team front to address any clinical quality and compliance concerns. • Regularly reviews clinical documentation including but not limited to treatment notes, treatment plans and level of care assessments and provides feedback to the clinical team, Clinical Directors/Supervisors, Executive Directors, VP of Operations, Assistant VP of Operations as needed. • Provide oversight of clinical documentation and feedback to Clinical Directors/Supervisors, clinicians, MHA/BHT's, CRS's, and others as appropriate. • Work in collaboration with Admissions, Billing and other departments to ensure proper delivery of services and maintaining compliance with state licensing and accreditation boards, as well as contractual requirements • Assess clinical competency of clinicians, both licensed and unlicensed, to monitor and safeguard services for clients as directed. • Point person/lead for compliance for various annual State licensing inspections and Accrediting-Body Surveys, in combination of working and coordinating with clinical team, as well as for all applicable MA/SCA reviews and insurance audits. • Facilitates group and individual trainings regarding compliance and proper protocol and tangent regulations for such documentation. • This position has oversight to the HIPAA regulations as well as compliance oversight in all facilities in a given territory. • Ensures compliance with Federal and State regulatory agencies and requirements, including an active understanding of all changes and revisions in policy and practice. • Oversees internal auditing process for the Division and any additional facilities that receive governmental funding, identifying deficiencies and training opportunities. Including the development and revision of monitoring tools, consistent auditing schedule. • Reviews and revises policies and procedures pertaining to compliance and regulatory requirements for Pyramid Healthcare. • Functions as the Privacy Officer for the Division, monitoring and maintaining the HIPAA privacy program; ensures appropriate documentation and reporting are completed. • Responsible for all external audits including response, coordination of review. Coordinates with Chief Compliance Officer and VP of Quality Management in development of responses, appeals, and self- auditing. • Educates staff with regards to quality risk management and regulatory compliance issues; • Meets with identified compliance lead staff at program level to ensure a systematic approach to identifying, prioritizing and assessing appropriate quality activities and interventions. JOB DESCRIPTION • Communicates any concerns about compliance of clinicians' work to clinicians, supervisors, and other appropriate individuals in a timely manner. • Works in collaboration with other Regional Quality Managers to review audit/licensing/accrediting outcomes and implementing necessary changes globally across all applicable programs. • Manages and identifies the trends and patterns of complaints, significant member incidents, and other pertinent reporting across the organization. • Work in collaboration to implement appropriate documentation and program changes with Director of PI and the quality team to ensure follow through with the new documentation, workflow, etc. • Maintenance and development of the compliance indicator tool. • Maintain confidentiality regarding privileged administrative and client information in a professional manner. • Other duties as deemed necessary Technical Competencies: • Understanding behavioral health and complex conditions • Application to practice • Assessment • Treatment planning and continuing assessment • Family, supports and referrals • Individual Counseling • Group Counseling • Documentation • Skillset within EMR system • Skillset within excel, word, smart sheets, etc. • Professional readiness and Ethical Responsibility • Population Specific Competency Education, Experience: 1) A Master's Degree from an accredited college with a major in psychology, social work, counseling, nursing (with a clinical specialty in the human services field) or other related field, licensure (LPC, LCSW, LMFT, etc.) and 2 years of supervisory and/or clinical experience. OR 2) A Bachelor's Degree from an accredited college with a major in psychology, social work, counseling, nursing (with a clinical specialty in the human services field) or other related field, licensure (LPC, LCSW, LMFT, etc.) and 2 years of supervisory and/or clinical experience. Job-related Behavioral Characteristics: Ability to operate in complexity, understanding various compliance regulations as well as services offered in all sites, developing/improving processes, and delegating when necessary. A working knowledge of HIPAA, Licensing, and CARF regulations. Excellent oral and written communication and interpersonal skills. Strong work ethic; operates in the longterm interest of the business. Demonstrates professionalism, leadership, confidentiality, strong social communication skills, time-management, organized. Must possess skills to communicate effectively and interact well with people of diverse backgrounds. Ability to problem solve by gathering and analyzing information, working well in an individual/ group problem solving situation, and showing initiative in problem solving. Maintains professionalism and does not show favoritism. Maintains consistency with clients, staff, visitors, and the public. Ability to handle a crisis situation and react appropriately. Flexibility and adaptable. Ability to make decisions in an objective and ethical manner. Ability to sustain a team environment, drive continuous improvement projects, confidentiality, excellent problem-solving skills and excellent communicator within the team framework. Ability to sustain a team environment. Pyramid CORE Values: We are committed and proud to live our CORE values and use them to inspire those around us. Our employees are expected to align with these values, behaviors and standards. We are held accountable for upholding these CORE Values: INTEGRITY is striving to be honest, transparent and ethical when dealing with clients, staff and the community. DEDICATION is demonstrating an unwavering commitment to always provide exceptional care and support to those we serve is needed daily. COLLABORATION is a steadfast, team-focused approach; working together to achieve excellence. PASSION is genuine, compelling and relentless desire to improve lives and support Pyramid Healthcare's mission.