This role provides leadership and support in the development and maintenance of clinical compliance and clinical risk management activities for the agency. Responsible for overseeing and ensuring adherence to all local, State, Federal, and regulatory requirements, standards, and policies governing the services provided by the Agency. This role plays a crucial role in maintaining ethical standards, legal compliance, and accreditation status and ensuring utilization of best practices and care thro... more details
Senior Director of Compliance (Sepulveda Quality Assurance)
This position is partially remote, and you have the option to elect into a 9/8 flex work schedule. The pay range for this position is between $144,440 - $160,490 annually.
About Didi Hirsch
Didi Hirsch Mental Health Services has been a national leader in whole-person mental health, crisis care, and substance use services since 1942 and is home to the nation’s first Suicide Prevention Center. We are a nonprofit organization providing care to nearly 200,000 people annually across our programs. Didi Hirsch has deep roots in community-based mental health and a commitment to providing culturally responsive services that are just and equitable.
As an organization, we value equity, diversity, and inclusion. More than 1,000 dedicated employees and volunteers make Didi Hirsch’s work possible. We intentionally recruit and retain a workforce that is reflective of the communities we serve and strive to cultivate a sense of belonging for them. We embrace employees and candidates from all backgrounds who want to help make this vision a reality.
Summary
This role provides leadership and support in the development and maintenance of clinical compliance and clinical risk management activities for the agency. Responsible for overseeing and ensuring adherence to all local, State, Federal, and regulatory requirements, standards, and policies governing the services provided by the Agency. This role plays a crucial role in maintaining ethical standards, legal compliance, and accreditation status and ensuring utilization of best practices and care throughout the agency.
Primary Duties
- Assists VP of Health and Innovation in the developing, implementing, and managing the Agency’s clinical compliance program which includes but is not limited to safeguarding client rights, ensuring client privacy, preventing fraud and abuse, addressing client grievances, HIPAA violations, and incident reporting.
- Leads or Co-leads compliance and clinical risk management committees and related activities.
- Collaborates with QI Division Director to establish internal compliance policies, determines relevant metrics, oversees internal audits to determine potential risks and areas of improvement agency wide.
- Interacts with all levels of management, employees, clients, external regulators, and legal counsel to address compliance related issues.
- Conducts compliance/privacy investigations, provides consultation to staff, maintains required documentation, tracks metrics, and develops, and implements policies and procedures.
- Manages incident reporting which includes but is not limited to reviewing critical incident reports, maintaining related policies and procedures, collaborating with stakeholders on conducting root cause analyses, collaborating with program leadership in developing and implementing improvement/corrective action plans, and monitoring ongoing compliance with improvement initiatives.
- Promotes an effective compliance culture by organizing training related to all regulatory requirements and best practices.
- Responsible for the management and administration of solutions used for managing critical incident reporting.
- Collaborates with QI Division Director on quality assurance and quality improvement activities agency wide.
- Leads all accreditation/certification agency-wide related activities which include but are not limited to initiating accreditation/certification, leading the agency through accreditation/certification and re-accreditation/re-certification activities. This includes accreditations and certifications with regulatory bodies such as Joint Commission Accreditation, Medi-Cal, and Community Care Licensure (CCL), among others.
- Ensures compliance with all accreditation/certification requirements.
- Tracks and maintains policies and procedures related to accreditation/certification.
- Monitors regulatory requirements and changes in the compliance landscape to ensure the Agency remains compliant with relevant requirements.
- Provides oversight of release of records/information according to regulations.
- Oversees all aspects of Health Information Management which includes but is not limited to release of records and health information exchange.
- Acts as the Privacy Officer.
- Oversees the development, maintenance, implementation and adherence of policies and procedures related to but not limited to: Accrediting body requirements, local, State, and federal laws, and regulations.
- Develop and implement internal policies and procedures related to Critical Incident Reporting, compliance/privacy, complaints and grievances.
- Responsible for the management and administration of solutions used for managing policies and procedures.
Position Requirements
- Master’s degree in healthcare, community mental health, public health, healthcare administration, or a related field.
- At least 5 years of experience in compliance, regulatory affairs, or related field in health care field; preferably in a behavioral health setting.
- At least 3 years of experience in a senior leadership role overseeing agency wide compliance programs.
- Experience developing, implementing, and monitoring compliance programs.
- Strong knowledge of local, State, and federal laws and regulations governing mental health services, including HIPAA, Medicaid, Medicare, and other relevant laws and regulations.
- Familiarity with Joint Commission Accreditation strongly preferred.
- Excellent analytical skills with ability to assess, understand and implement complex regulatory requirements.
- Ability to develop quality and process improvement plans.
- Strong understanding and data to drive actionable insights.
- Support the values and mission of Didi Hirsch as related to employment.
- Have strong organizational skills as well as analytical, numerical, and reasoning abilities.
- Know and comply with Agency policies and procedures, confidentiality/HIPAA, DMH policies and documentation guidelines, and other state, federal regulations relating to quality assurance and improvement.
- Have working knowledge and proficiency in Electronic Health Records.
- Demonstrate effective relational, collaboration, leadership, and management skills.
- Present data, ideas, information, and viewpoints clearly, both visually, verbally and/or in writing. Demonstrate experience in presenting information in large group formats.
- Efficiently use Microsoft Office Suite (including Excel, Word, etc).
- Manage employee and student performance consistent with defined Didi Hirsch processes.
- Utilize analysis, experience, and judgment to make solid business, administrative, and clinical decisions.
- Demonstrate commitment to team objectives and Didi Hirsch philosophies.
- Adapt to changing needs by acquiring new skills and knowledge.
- Current California driver’s license and a driving record acceptable to the Agency’s insurance carrier.
A future where everyone has equitable access to care and is empowered to achieve optimal mental health and well-being.
Didi Hirsch provides compassionate mental health, substance use, and suicide prevention services to individuals and families, especially in communities where discrimination and injustice limit access.
Excellence: We are constantly innovating, learning from the communities we serve, and applying the latest research to advance best practices. We uphold the highest ethical standards to ensure we are providing compassionate and excellent care.
Diversity & Inclusion: We value diversity of background, experience, and ideas, committing to a workforce representative of the communities we serve. We celebrate differences and prioritize creating a sense of belonging.
Equity: We are dedicated to maintaining equitable practices in our healthcare delivery and workplace culture, and we work to dismantle disparities and discrimination within both systems of care and society.
Well Being: We are devoted to the well-being of our staff, volunteers, and communities, and believe healthy teams lead to healthy clients.
Advocacy: We advocate across all levels of government and use our voice to reduce barriers to care, including stigma, systemic racism, and parity across payers, with the goal of access to high quality, integrated healthcare for all.
Community Engagement: We build partnerships in the community and across sectors to create a more inclusive and responsive mental health ecosystem and enhance greater accessibility to care and support.
