The Director of Quality and Compliance will provide direction and oversight of the development, implementation, and evaluation of all quality improvement and compliance program, including, but not limited to policies, procedure, practices, and initiatives agency-wide to ensure compliance in accordance with all applicable federal, state, and local regulatory requirements and licensing, accreditation, and Agency standards. The Director of Quality & Compliance will devise and drive quality initiatives throughout the Agency that have successful and measurable impact on program outcomes, strategic and business goals and objectives, and established Quality Improvement (QI) program guidelines and metrics.
In collaboration with the Senior Vice President of Strategy and Community Engagement and other key stakeholders develop and implement the Agency’s Quality Improvement (QI) program to include, but not limited to methodology, philosophy, general approach, metrics and measurements, policies, procedures, and best practices
Maintain audit readiness by ongoing training, competency assessment, audit, monitoring or metrics and corrective action
Work closely with program management and staff to identify opportunities for improvement, document trend analysis, develop ongoing training and appropriate action plans to address performance issues and minimize violations of compliance and licensing standards and requirements
Oversee and manage the accreditation process Agency-wide; manage outstanding survey documentation list for timely submission of information
Conduct a systematic review process (mock survey) to ensure all program sites are prepared and actively participating in the accreditation process
Design, develop, implement, and conduct effective training programs for management and staff in the areas of QI and compliance, HIPPA compliance, and accreditation standards
Design, develop, implement and communicate policies and procedures for compliance with new and/or changing federal, state, and local regulatory requirements, CARF, licensing standards and program regulations
Design, develop, implement, and evaluate interventions to improve performance for key indicators of program outcomes and business operations, goals, and objectives
Provide regular, ad hoc, and special reports to Senior Leadership, management, and staff on QI outcome measures and improvements to increase understanding, use of QI tools, and communicate program outcomes as it relates to QI standards
Oversee and manage reporting of Performance and Quality Improvement metrics and outcomes to federal, state, local regulatory agencies and funders, as needed
Analyze and evaluate the effectiveness of programs and operations in meeting established goals and objectives in compliance with Agency, licensing, and accreditation standards and other regulatory requirements
Ensure the application of internal controls and processes to maintain the rights of all our service populations, confidentiality and full disclosure
Provide management and oversight of accreditation surveys
Collaborates with Human Resources Department and others as appropriate to develop compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees and management.
Monitors matters pertaining to corporate compliance including conducting corporate compliance risk assessments in collaboration with supervisor; identifies potential areas of compliance vulnerability and risk; develops and recommends to Sr VP of Strategy and Community Engagement corrective action plans for resolution of problematic issues; implements approved plans. Reports on matters pertaining to corporate compliance including providing general guidance on how to avoid or address similar situations in the future.
Collaborates with other departments (Human Resources, Finance, Facilities, programs) to direct compliance issues to appropriate existing channels for investigation and resolution.
Develops, maintains and revises policies and procedures for the general operation of the compliance program and its related activities to prevent illegal, unethical or improper conduct.
Staff Management and Development
Provide ongoing support and coaching to all direct report staff to ensure the department is operating effectively in accordance with Agency and licensing standards, established goals and objectives, and federal, state and local regulatory requirements.
Interview, hire, and train new staff and develop and implement ongoing staff development trainings.
Coach and support staff to ensure they have the necessary tools and resources needed to optimize performance and ensure established program goals and service delivery is achieved at the highest quality level, in a timely manner, and within budget; develop staff members to their professional potential, foster teamwork within the program, and ensure a seamless service delivery to children and their families.
Regularly review employee performannce and provide supportive feedback.
Conduct 90-day and annual evaluations per established completion date.
Work collaboratively with all internal and external stakeholders to develop and implement a QI program and activities Agency-wide
Work in partnership with internal stakeholders, clients, and auditors/surveyors to ensure all QI policies and procedures are operating efficiently and effectively to meet strategic and business goals and objectives, licensing and accreditation standards, and other federal, state, and local regulatory requirements.
Work as part of the team and show professionalism at all times by modeling and demonstrating a positive attitude and positive working relationships.
Bachelor’s degree in Quality Improvement, Risk Management, Business Administration, Management, or closely related field
5 years’ progressive experience in quality improvement, compliance, or Risk Management
Previous expereince working in a child placing agency, RTC, child health and welfare or relevant field
Previous experience with CARF audit preparation
Previous experience working with and interpreting Texas minimum standard guidelines
Strong and effective time management and organizational skills with the ability to prioritize and balance competing priorities and meet deadlines
Strong interpersonal and people skills with the ability to effectively work with a diverse group of people and build strong working relationships
Ability to use effective judgement; strong decision making skills
Strong analytical skills
Strong written, verbal, and presentation skills with the ability to articulate the value proposition of Risk Management activities to business process owners in order to gain support and buy-in
Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook
Master’s degree in Business Administration, Quality Improvement, Risk Management, or closely related field
7 years’ progressive experience in quality improvement, compliance, or Risk Management
Physical Demands & Work Conditions
This position requires sitting and looking and using a computer for long periods of time
Lift, push, pull, move up to 25 lbs.
The physical requirements for this position with or without reasonable accommodation are representative of those that must be met by an employee to successfully perform the essential functions of this position. While performing this position the employee with or without reasonable accommodation should have the ability to walk, stand, sit, kneel, speak, and hear with aid, see, read, reach with arms and hands, and use equipment that is essential to performing the job, such as a computer, copier, fax machine, telephone, and automobile, if applicable. This position will require continuous viewing of a computer screen. This position will require sitting and standing for long periods of time, frequent walking, bending, kneeling, stooping, and lifting, carrying, or moving items up to 50lbs with or without assistance.
The statements herein indicate the general nature and essential duties and responsibilities of work performed by an employee in this position. It is not intended to be an exhaustive list of all duties, responsibilities, knowledge, skills, and abilities required to perform the job. Management may assign or reassign duties and responsibilities of the job and may request the employee to perform other duties and responsibilities not listed at his/her discretion. This job description is not a contract between the employee occupying the position and the employer. Upbring is an at-will employer. Equal Employment Opportunity/M/F/disability/protected veteran status
Who We Are:
At Upbring, we’re changemakers determined to create a world where all children are cherished. We understand that breaking the cycle of child abuse means more than removing children from harmful situations and providing clothing, food and shelter. Because when the cycle is broken, it means children get to live every moment of every day with every inch of their whole hearts. So you’ve got to help children heal physically, emotionally and spiritually. Upbring does this.
We’ve been helping children thrive for more than 135 years, and we’re not stopping. We have an opportunity to shape not only the way we deliver our programs and services, but shape the way Texas treats children. We have Faith in Every Future.
What We Do:
Upbring is raising the standards for what childhood should be.
The harsh realities of child abuse and neglect often extend beyond the four walls of a home and into the fiber of our communities—in many cases stemming from a cycle of crime, economic disparity, mental health disorders and substance abuse. Every case of child abuse is different from the next because every child is unique, and so are their needs.
That’s why in order to break the ...generational cycle of child abuse, Upbring meets children and families in need right where they are. We then surround them with the services they need right then based on five key markers of every child’s success: safety, life skills, education, health and vocation. We call this our continuum of care.