Compliance Monitor

Description

Position will ensure Haymarket Center care follows clinical guidelines, standards of care and standards of practice, policies, procedures and regulations of external regulatory and accreditation bodies. 

The Compliance Monitor is expected to ensure an ongoing quality improvement/assurance (QI/QA) system by ensuring the appropriateness of services provided, the quality of service delivery, a reasonable length of stay and that evidence based practices are applied to model fidelity. The Compliance Monitor is expected to help clinical staff develop action plans to close identified compliance gaps, which may involve small improvement projects and helping staff to understand reasons for structuring documentation and workflows. 

ESSENTIAL FUNCTIONS:

• Review client charts to ensure that all procedures have been followed and are culturally appropriate
• Review treatment plans to ensure plans to ensure patient needs are being documented.
• Monitor records to ensure client progress is meeting goals and objectives. 
• Validates that continuing stay criteria are being met.
• Confirms that discharge criteria and continuing/aftercare plans are in place and consistent with objectives met.
• Documents reviews in a timely manner and recommend quality improvement activities necessary.
• Conduct follow-up review of the record to ensure that all initial errors were corrected and transfer/discharge procedures were applied when applicable.
• Report review findings to the programs immediate supervisor and other applicable personnel via Microsoft Outlook and enter on an excel spreadsheet. Provide a weekly report to QA manager. 
• With QA Manager and Director of QA, develop and implement improvement projects to help clinical staff make necessary improvements and sustain those improvements. Assist the Director of Staff Development & Training with identified topics for clinical educationand help deliver education and training tools to address the root causes of compliance gaps.
• Maintain a presence on Haymarket treatment units, clinics and treatment areas to monitor actual staff practices and identify deviations from policy and procedure. Directly visit teams to present results of audits and coach on improvement projects when appropriate projects when appropriate. 
• Complete administrative tasks to support functionality of the quality of department, including supporting the Records team when necessary. 
• Ensure coverage and after hours coverage procedures are followed, addressing any barriers in assessing services.
• Monitoring QI/QA Outcomes.
• Perform other duties as assigned. 

Requirements

  Education, Experience and Skills required;

• Certified Alcohol and Drug Counselor (CADC) or licensed in IDFPR with SUD experience
• Certified Content Expert (CCE) of Certified Healthcare Compliance (CHC) (Preferred)
• Familiarity with Administrative Code Part 132, 140, 2030, 2060, 2090, and CARF Behavioral Health Standards and JCAHO.
• Familiar with Health Center Program Standards as set forth by HRSA and CCBHC standards as set down by the state of Illinois and SAMHSA.
• At least 2 years of record keeping experience with a substance abuse treatment facility or a combination of skills and qualifications.
• Must be detailed oriented, demonstrate proficient written and verbal skills. 
• Relate well with others. 
• Able to work independently with minimal supervision.