General Summary of Duties: The Compliance Manager oversees and is responsible for developing, planning, organizing, and directing all functional activities related to the Agency's safety, risk, compliance, and ethics programs.
The Compliance Manager will work collaboratively with senior leaders and employees across the Agency to implement policies and procedures, conduct internal monitoring and auditing, facilitate effective training and education to ensure an effective compliance strategy.
Develops and provides leadership for an agency-wide compliance, risk management, and ethics framework that ensures employees, Agency leaders, and Board members are knowledgeable about and comply with relevant and applicable federal and state laws, WAC, DHHS, DOH, OIG, and other regulations, and all Agency policies and procedures.
Manages day-to-day operation of the Compliance and Risk Management Programs.
Develops, initiates, maintains, and revises policies and procedures for the Compliance Program and related activities (HIPAA Privacy). Develops and periodically reviews and updates the Agencys Code of Conduct.
Ensures all Agency policies are updated and maintained in accordance with Washington Administrative Code Standards.
Completes client termination process.
Maintain a detailed knowledge of contractual requirements and state and/or county contract requirements. Review Agency contracts to ensure compliance.
Measure client outcomes through effective client satisfaction surveys, program evaluations, and other quality indicators.
Serves as the point person for incident reports, client grievances, and monitoring of the compliance hotline and develops and oversees a system for uniform handling of the overall process.
Coordinates investigations, resolutions, and response efforts with the Quality Improvement Committee and Agency leaders as appropriate to ensure timely follow-up and resolution.
Develops an annual internal audit plan to test compliance with agency policies and procedures across the Agency, identifying high-risk areas to prioritize compliance efforts.
Plans and conducts internal audits to monitor compliance across operational and clinical areas of the Agency.
Prepares written audit reports, proposes corrective actions and follows up to address deficiencies.
Evaluate the adequacy and effectiveness of internal and operational controls.
Prepares an annual risk assessment summary identifying key areas of compliance deficiencies, policy changes, audit findings, and incident reporting trends.
Prepares quarterly summary of Compliance issues for Senior Leadership and Board of Directors.
Works to prevent, detect, and correct compliance risks through d esigning, implementing, and monitoring policies, procedures, and internal controls related to respective compliance requirements in coordination with management and other parties.
Create and maintain documentation systems and processes as needed to track, trend, and manage compliance notifications, issues, corrective action plans, audit results, etc.
Serves as point person for all external audits and government investigations, except financial and human resources, where will serve in a collaborative capacity as needed and appropriate.
Ensures timely coordination of data collection, timely follow-up on deficiencies, development of corrective action plans in collaboration with stakeholders, training plans as appropriate, and communication of findings to senior leaders.
Conducts follow-up testing to ensure implementation of corrective action plans and ongoing compliance.
Determines compliance metrics and establishes a system for tracking them.
Remain up to date on federal and state laws related to the Agency and ensure that policies are updated accordingly.
Chair Compliance & Risk Management Committee
Serves as a member of the Agencys Safety Committee, providing consultation and recommendations on relevant client safety and risk management issues affecting the organization.
Promotes and ensures risk and client safety program integrity through adequate oversight of staff functions, data collection, and reporting.
Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate training for new employees and ongoing training for all employees and managers.
Institutes and maintains an effective compliance communication program for the organization, including promoting heightened awareness of the Code of Conduct and understanding of new and existing compliance issues and related policies and procedures.
Bachelors degree in Social Work, Psychology, Behavioral Health or related field OR High School Diploma or GED with four years related experience.
At least five years of progressive experience in health care compliance/risk management roles.
Certified Compliance & Ethics Professional (CCEP), Certified in Healthcare Compliance (CHG), or ability to attain certification within one year of hire.
At least three years of management experience.
Masters degree in Nursing, Social Work, Psychology, Behavioral Health, or related field.
Strong knowledge of EHR systems and ability to become a super-user of KMHSs EHR.
Three or more years of relevant experience in a mental health setting are strongly preferred.
Kitsap Mental Health Services (KMHS) is a 501(c)(3) not-for-profit organization providing a full range of inpatient, outpatient, and residential behavioral health services for children and their families, adults and older adults.
We know from experience that mental illness is treatable and that people can and do recover and return to full, normal activity. KMHS serves more than 6,500 children, youth, adults and families each year, providing hope, strength and stability when it’s needed most. As a respected leader in the community mental health and substance use disorder field since 1978, we’ve earned a reputation as a vigilant steward of public funds. KMHS employs more than 500 individuals staffing dozens of programs and serving Kitsap residents of all ages and backgrounds.