CBI Banner

OPERAT - Standards & Compliance Manager - 00725

Mesa, AZ, USA ● Virtual Req #749
Tuesday, June 1, 2021
Community Bridges, Inc. (CBI) is an integrated behavioral healthcare agency offering a variety of different programs throughout Arizona. CBI provides residential, outpatient, inpatient, patient-centered medical homes, medication-assisted treatment, and crisis services to individuals experiencing crisis, opioid use disorder, homelessness, and mental illness.

General Description:  

The Compliance Manager is assigned to the Quality Management department and is responsible for ensuring compliance with the standards set forth by the governing bodies listed below.  This position is responsible for areas of compliance pertaining to licensing, accreditations, HIPAA.  This position works to ensure that all clinical programs and sites are audited routinely resulting in comprehensive summary reports including recommendation submitted to upper management for review.    Summary should include a narrative of what was reviewed and any determinations that were made in the process regarding policy and process.  Recommendations may include additional training, policy changes, processes changes, disciplinary actions. 

 

Each area below is defined by specific function as it relates to policy, process, and the governing rules set forth by the Department of Behavioral Health Services (DBHS), Regional Behavioral Health Authority (RBHA), Department of Medical Facilities Licensing, and the Code of Federal Regulations.  Each employee will be held accountable and responsible for fulfilling each of these duties as well as having the capability to carry them out. 

Specific Functions & Duties: Each discipline is governed by specific policy and process.  It is the responsibility of the employee to read, and learn the associated policy and processes as they will be held responsible for carrying out their duties in a competent and ethical manner.



Compliance

·         Responsible for all initial and renewal applications for medical licensing including but not limited to all outpatient treatment centers, inpatient facilities, and substance abuse transition centers.

·         Responsible for all initial and renewal applications for residential licensing.

·         Monitors all submittal deadlines including renewal deadline.  Ensures that all required information and payment is submitted on time.

·         Responsible for ensuring all sites that provide laboratory services have CLIA waivers to complete the lab work. 

·         Assist in the development of monitoring tools for record reviews, site audits for medical and behavioral health services in accordance with CMS, ADHS/DBHS, T/RBHA, AHCCCS, CARF, Joint Commission, NCQA and A.A.C rules and standards in conjunction with the Associate Director of Standards & Compliance.

  • Coordinates site audits monthly in conjunction with the Quality Management team or designee in order to audit based on internally developed tools based off of Medical Licensing, AAC, Joint Commission, NCQA and CARF requirements. 
  • Site audit reviews will be summarized in a comprehensive report including recommendations for improvement and provided to the Deputy Chief of Standards & Compliance and Program Leadership as they are completed.
  • Works closely with the Deputy Chief of Standards & Compliance to ensure that CBI works to be in compliance with HIPAA laws.  Assists in annual HIPAA Risk Assessments.
  • Protects each patient’s confidentiality within the parameters of federal guidelines and established policy and process.
  • Adheres to established policy and process for this assignment.
  • Other duties as assigned by supervisory and administrative support.   


Risk Management

  • Responsible for ensuring that a comprehensive analysis and review of all Significant Events are completed by a Compliance Nurse.  Provides a monthly comprehensive summary of trends and recommendations for improvement and provided to the Associate Director and Deputy Chief of Standards & Compliance as they are completed.
  • Responsible for ensuring that a comprehensive analysis and review of all Incident Accident Death Reports are completed. Provides a monthly comprehensive summary of trends and recommendations for improvement and provided to the Associate Director and Deputy Chief of Standards & Compliance as they are completed.
  • Adheres to established policy and process for this assignment.
  • Other duties as assigned by supervisory and administrative support.   


External Audits

  • Acts as the ‘point person’ for ad hoc licensing audits by coordinating reviews and fielding questions or concerns that arise throughout the course of the review.
  • Assists for CARF accreditation survey preparation as required.
  • Protects each patient’s confidentiality within the parameters of federal guidelines and established policy and process.
  • Adheres to established policy and process for this assignment.
  • Other duties as assigned by supervisory and administrative support.   

 

Supervision Responsibilities

  • Provides direct supervision to compliance staff.
  • Provides coaching and supervision to compliance staff.
  • Participates in the hiring process of compliance staff.
  • Provides initial and ongoing training to compliance staff.
  • Identifies areas for further training with compliance staff.
  • Conducts a monthly information/training meeting with all compliance staff.
  • Protects each patient’s confidentiality within the parameters of federal guidelines and established policy and process.
  • Adheres to established policy and process for this assignment.
Education Requirements:


  • Bachelors Degree in a Behavioral Health field or Business Administration
  • Valid AZ drivers license  



 

CBI Offers an excellent benefits package!

  • Medical, Dental, Vision, Disability, Life, Supplemental plans - Hospital indemnity/ Critical Illness, Pet Insurance, Dependent Care Savings, Health Care Savings, 401K with employer match - 100% vested upon enrollment, Generous PTO accrual, Wellness programs, Tuition Reimbursement and Scholarship Programs, incentives, and more!
  • For the past four years, The Phoenix Business Journal has recognized CBI as one of the top ten healthiest mid-size employers in the Valley.

CBI treats patients from all different walks of life and believes in maintaining the dignity of human life. Recovery is possible!

Other details

  • Pay Type Salary
  • Mesa, AZ, USA
  • Virtual