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Summary

This position is responsible for supporting quality and compliance improvement initiatives that strengthen Epworth’s programmatic and operational efforts. This is a full-time position supervised by the Senior Director of Human Resources. The Director of Quality and Compliance cultivates a healthy workplace environment by leading with cultural competence, fosters teamwork throughout the organization and program department, leads change efforts in support of Epworth’s continuous improvement of programmatic and operational efforts, values relationships with all stakeholders (clients, staff, agency partners), and drives the organization to achieve maximum impact on client outcomes.

Primary Responsibilities:

Quality and Compliance

• Maintain Agency-wide scorecards and performance metrics.

• Draft, revise, and distribute agency policies and procedures reflecting legislation and licensing requirements

• Collaborate with program leaders and other department leaders to improve key metrics.

• Works collaboratively with Training and Compliance Coordinator to ensure employee training is up-to-date and properly scheduled on an annual and bi-annual basis

• Design and deliver compliance and safety training for employees and volunteers, where appropriate

•  Lead Quality and Compliance Operational Improvement sessions monthly to identify and improve goals set forth in agency and department scorecards.

• Lead quality improvement initiatives agency-wide.

• Collaborate with Development and Efforts To Outcomes (ETO) platform to maintain ETO with accurate information so that performance outcomes can be measured using data within ETO.

• Use information in different systems (ETO, Relias, Accounting System, Donor Database, etc.) to source and analyze data for decision-making.

• Initiate, coordinate, and collate survey-related data, information, and trends for both client surveys and funder/referral agent surveys.

• Create agendas, prepare documents/reports, and compile meeting minutes and action plans as needed to ensure data-driven decision-making.

• Assist with agency and/or program reporting as needed.

• Submit reports in collaboration with program personnel to ensure accurate program depiction, language, and data.

• Assist the Development Team with grant monitoring and compliance.

• Leads HMIS and HIPAA regulatory compliance to ensure that proper confidential laws are being upheld and ensure that document and recordkeeping procedures are being maintained according to HIPAA documentation regulations.

• Track, interpret, and implement local, state, and federal child welfare mandates

Quality and Compliance

• Monitors and provides oversight to all programs to ensure effectiveness/compliance with policy, licensing, accreditation, and funder requirements while supporting employees to complete external or internal audits in compliance to ensure program success.

• Leads and monitors agency safety and Infection protocols by identifying and developing procedures to minimize agency hazards.

• Utilizes LMS software and customized programs to meet business needs, including adding/edit Users, data entry, and report generation.

• Serves as Internal/External Liaison and primary point of contact for investigations, licensing, state inspections, and contract audits

• Prepares and maintains inspection reports, complaint investigation reports, and documentation required to provide evidence of compliance or non-compliance if legal action is required.

• Conducts and supports the investigation and resolution of incidents involving clients reported through OHI, and from other methods, in collaboration with the department as appropriate.

• Work collaboratively with Development and Program Directors to ensure compliance with grants/contract expectations.

• Conduct regularly scheduled audits reviewing youth treatment plans, case documentation, and building codes – working closely with maintenance and program leads to ensure building code compliance

• Assists with coordination and follow-up of audits and investigations conducted as part of the compliance privacy monitoring program.

• Perform other duties as assigned relative to compliance, metrics, and deliverables

Qualifications:

• Bachelor's Degree in a related field
• 3-5 years working in child welfare, juvenile justice, or regulated healthcare/social services environment for youth
• Excellent record-keeping, conflict resolution, risk assessment, and strong working knowledge of ETO
• Ability to use or learn software applications such as ETO, Accounting, Donation, Donor/Grant Software, and Relias (Learning Management System) preferred.
• Ability to use Microsoft Applications such as Word, Excel, PowerPoint, and Teams
• Excellent communication and presentation skills

Supervisory Responsibilities: None

Job Knowledge, Skills, and Abilities:

• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, or government regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions from groups of managers, public groups, and/or clients.
• Reasoning Ability: Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to deal with several abstract and concrete variables.
• Computer Skills: E-mail, Microsoft Word, and Microsoft Excel.
• Physical Demands: While performing the duties of this job, the employee is regularly required to communicate effectively.

Physical Requirements

• The physical requirements of this job include sitting, standing, walking, and climbing stairs on a regular basis, lifting up to 25lbs, and pulling and/or pushing on occasion.
• Required to visit Epworth sites to ensure compliance measures are consistent agency-wide