Director of Compliance Quality & Risk Management

Director of Compliance Quality & Risk Management (CQRM) – Affiliate Wide

Full-time. The Director of CQRM is responsible for developing, coordinating, and implementing the agency-wide CQRM program in collaboration with heads of all departments, including Patient Services, Finance, Revenue Cycle, Human Resources, Development, Information Technologies, and Grants & Programs.

Planned Parenthood of Central and Western New York (PPCWNY) protects and provides health care and education that empowers individuals and families. With respect. Without judgment. No matter what.

• Review and update existing, as well as develop new manuals, policies, procedures, protocols, and forms in accordance with PPFA standards and guidelines, federal and state guidelines, and PPCWNY requirements in areas including but not limited to:
  Exposure Control, Infection Prevention, HIPAA Privacy, Health Care Compliance, Records Retention/Destruction.
• In collaboration with agency leadership, ensure that all federal, state, local and PPFA compliance requirements are included in the CQRM workplan and met.
• Ensure that mandatory and other in‑services, including, but not limited to HIPAA, OSHA, corrective action needs, Infection Prevention, etc. are offered and are completed by required staff.
• Manage the accreditation and corollary processes for PPFA.
• Assist with organization of documents for Article 28, Title X, OMIG, third‑party payer, and other on‑site review processes.
• Serve as the Agency’s HIPAA Privacy Officer. In collaboration with the HIPAA Security Officer, and the Medical Records Consultant, design and implement PPCWNY’s HIPAA policies, procedures, and processes, including determining “need to know” information for staff, staff training about HIPAA, record request and retention/destruction processes, and review and monitoring of organizational compliance.
• Serve as the Agency’s Health Care (Corporate) Compliance Officer. Develop and manage the affiliate Health Care (Corporate) Compliance program, including creating compliance policy and procedures, monitoring compliance, and reporting compliance deficits to the President and CEO. Coordinate internal investigations and pursue corrective actions with all internal departments, contractors, agents, subcontractors, independent contractors, and the State.
• Develop trainings for staff, including activities for Corporate Compliance & Ethics Week (each November).
• Review all legal correspondence regarding patient services and operations, and initiate discussion with Medical Director, VP of Health Services, President and CEO, and Agency, as well as PPFA counsel, as needed.
• Oversee the Incident Management system (AIMS), follow‑up with staff and supervisors, as needed, in order to investigate, develop, run, and assist with Root Cause Analyses and Plan‑Do‑Study‑Act cycles, as well as Corrective Action Plans as needed.
• Coordinate all quality improvement activities including on‑site audits.
• In collaboration with the Medical Leadership Team, provide ongoing training and develop training tools for all health center staff on quality improvement as it relates to clinical practices.
• Provide training and serve as a resource for agency leaders and staff on how to use the Model for Improvement and Plan‑Do‑Study‑Act cycles to make meaningful changes.
• Write and present reports summarizing compliance issues, quality improvement activities, and risk mitigation activities for staff training, leadership awareness, Board of Directors (BOD) knowledge and per PPFA, NYS Department of Health, US Health and Human Services and other agency requests. The Director of CQRM is accountable to the BOD and shall report compliance concerns directly during a board meeting’s executive session.
• Show respect to all internal and external customers for differences in backgrounds, lifestyles, viewpoints and needs.

• Build the CQRM team necessary to manage the agency’s CQRM needs as well as being prepared for projected organization growth, including department succession plans and supervises the department.
• Ensure that the responsibilities, authorities, and accountabilities of all direct reports are…