SERV Behavioral Health System

Quality and Compliance Coordinator

01. Corporate Office - Ewing, NJ - Full Time


SERV, a well-established leader in behavioral healthcare in New Jersey, supports people with mental illness and/or intellectual/developmental disabilities as they achieve greater independence and life satisfaction through a wide range of services.

 Reporting to the Senior Vice President of Quality and Compliance, the Quality and Compliance Coordinator will ensure compliance with requirements established by accrediting bodies and funding sources, as well as SBHS policy and procedures.  This is a fully onsite in our Ewing headquarters.
The Coordinator will promote a culture of compliance through upholding and communicating laws, regulations, policies, standards and core values.  He or she will facilitate effective decision making and collaboration with operations, and manage alignment with SBHS organizational goals, quality improvement plans, compliance plans and risk management programs to meet and exceed service delivery expectations. 

Responsibilities

  • Maintains up-to-date knowledge of applicable regulations (including New Jersey mental health and DDD) and accreditation standards
  • Oversees compliance monitoring systems to measure compliance with state and federal regulations, accreditation standards and policies and procedures
  • Supports operations to develop and monitor corrective action plans in response to adverse actions; provides technical assistance and direction
  • Conducts chart reviews, physical plant inspections and other assigned audits
  • Assists in policy review and development, ensuring that policies comply with requirements and are updated as needed
  • Oversees incident reporting system in accordance with established procedures
  • Ensures submission of State reportable unusual incident reports as required by law
  • Manages monthly trended incident reporting data; submits quarterly reports to operations for review and action
  • Provides support to Operations to follow through on critical events and identify methods to improve safety and minimize risk to consumers and employees
  • Leads and conducts internal investigations involving alleged abuse, neglect, exploitation, and/or other compliance-related issues;  reviews relevant documents and interviews witnesses, prepares written summaries, analyses of facts and investigation reports;  ensures accuracy and consistency of compliance investigations
  • Works in conjunction with the SVP of Quality and Compliance to investigate deaths and/or higher level incidents.
  • Provides oversight of the SERV Safety Manual procedures and practices throughout the organization. Monitors for compliance and proactively identifies areas for improvement.  
  • In partnership with Operations and the SVP of Quality and Compliance, assists with writing and reviewing the annual CQI plan and performs ongoing analyses to support organizational goals
  • Supports Operations with monitoring process/system improvement activities to improve service delivery
  • Implements and maintains systems and processes for effective CQI communication with operations
  • Responsible for receiving and disseminating CQI data and reports at the program level
  • Ensures consumer, family and other stakeholders input is gathered for quality improvement activities
  • Collaborates with operations to design the strategy for completing the satisfaction survey process, and assists with developing improvement plans in response to surveys
  • Responsible for monitoring implementation and sustainability of quality systems across programs
  • Collects and verifies data for key performance indicators and outcomes measures
  • Analyzes data and proactively identifies opportunities for improvement; partners with operations and the SVP of Quality and Compliance to develop and implement strategies towards improvement
  • Assists in the identification and presentation of outcome measures; participates in the design, execution and analysis of evaluation measures and key performance indicators
  • Additional duties as assigned or as needed to support departmental or organizational goals
Qualifications & Skills
  • Familiarity with New Jersey mental health, DDD and/or DCF regulations
  • Ability to comprehend and interpret complex regulations
  • Ability to respond with flexibility and efficiency to frequent changes in task focus, competing priorities, and multiple deadlines.
  • Commitment to maintaining confidentiality and protecting sensitive information
  • Ability to research, formulate logical conclusions and/or alternatives, make recommendations, and implement solutions Superb analytical and comprehension skills
  • Excellent verbal and written communications skills and presentation skills
  • Ability to work quickly and accurately under minimum supervision with close attention to detail
  • Computer skills including MS Office (Word, Excel, PowerPoint); experience with contract management software strongly preferred
  • Ability to make independent decisions and sound judgments
  • Ability to work a flexible schedule including nights and weekends
  • Reliable transportation and the ability to travel to program sites throughout New Jersey
  • We are relocating in Hamilton NJ late 2024
Required Licenses or Experience
  • Associate degree in healthcare administration, business administration, science or related field. Bachelor’s Degree preferred.
  • Valid driver’s license in the state of residence
  • Experience working with NJ DDD, DCF DMHAS, and/or CARF strongly preferred
  • Experience with compliance investigations
  • 5+ years related experience
#INDPR1

EEO STATEMENT

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, veteran status, or any other characteristic protected by law.

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