PURPOSE STATEMENT:

The Director, Quality and Compliance is responsible for ensuring compliance with state and federal laws and regulations, and as such, will be responsible for providing expert guidance and advice on all aspects of policy development, clinical protocols, critical incident reporting, regulatory submissions, certifications and on-going regulatory compliance in all Acadia facilities.

ESSENTIAL FUNCTIONS:

1. Monitor compliance with dosing, administration, and medication inventory.
2. Manage medication inventory programs within the CTC division such as nurse trainings, CSOS management, assigning and monitoring POA use, procurement, Acquisition and DeNovo implementation procedures.
3. Assist with variance investigations, provide guidance on resolutions, electronic inventory management, and incident reporting.
4. Sets expectations, develops plans, and manages processes to measure, assess and improve the quality of internal medication management procedures and/or regulatory/accreditation compliance by measurable results in assigned facilities.
5. Develop, review, and update internal due diligence policies and procedures and related outcomes measurement, patient satisfaction, clinical/financial scorecards to ensure ongoing compliance with federal, state, and other third-party regulatory requirements.
6. Respond to alleged violations of rules, regulations, policies, & Codes of Conduct by evaluating and recommending investigations as appropriate. Coordinate resolution of ethics reports with VP and/or AVP of Clinical Services/Compliance, General Counsel and as indicated Acadia Director of HR.
7. Initiate and lead communications with regulatory agencies as appropriate.
8. Develop/maintain proficiency in regulatory planning strategy and the submission of regulatory plans. Develop corrective action plans for the resolution of problematic issues or to address areas of compliance vulnerability.
9. Ensure proper facility reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
10. Ensure proper facility reporting of patient and medication related incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
11. Translate standards, requirements and policies into terms or processes meaningful to the target program.
12. Develop and evaluate the goals of the Company and prioritize the work in accordance with the strategic objectives of Acadia Healthcare.
13. Maintain regular communication with Medical Providers/ Nursing Staff/leadership staff at assigned facilities regarding clinical and regulatory/accreditation issues.
14. Work collaboratively with corporate staff, physicians, risk management, and other corporate leaders to address performance improvement and safety issues.

OTHER FUNCTIONS:

• Performs other duties as assigned.

STANDARD EXPECTATIONS:

• Complies with organizational policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality.
• Communicate clearly and effectively to person(s) receiving services and their family members, guests, and other members of the health care team.
• Develops constructive and cooperative working relationships with others and maintains them over time.
• Encourages and builds mutual trust, respect, and cooperation among team members.
• Maintains regular and predictable attendance.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• LVN or Registered Nurse.
• A minimum of five years’ experience in behavioral health - MAT.
• Operations/healthcare industry experience preferred.
• Knowledge of DEA Regulations 1300, the Joint Commission, CARF and other accrediting and oversight agencies.
• Experience in conducting complex compliance investigations, preferably in healthcare.
• Advanced computer skills including Microsoft Office; especially Word, Excel, and PowerPoint.
• Knowledge of office administration procedures with the ability to operate most standard office equipment.
• Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external.
• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
• Self-motivated with strong organizational skills and superior attention to detail.
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.
• Capable of working within established policies, procedures and practices prescribed by the organization.
• English sufficient to provide and receive instructions/directions.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Not Applicable

SUPERVISORY REQUIREMENTS:

This position is an Individual Contributor

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances
(e.g., emergencies, changes in workload, rush jobs or technological developments) dictate.

AHCORP

#LI-TB1