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Position Summary The Compliance Specialist is responsible for developing and managing a quality improvement plan comprised of strategies to ensure compliance with applicable laws, regulations, and accreditation standards. This individual will oversee peer review activities and manage both external and internal audits, including reviewing records, reports, and other relevant activities affected by regulations. The Compliance Specialist shall generate detailed audit reports of findings and help implement a plan to address such findings, including implementing evidence based practices and performing fidelity monitoring. The Compliance Specialist shall ensure all quality improvement efforts are executed using the industry standard quality improvement / monitoring methodology. Primary Functions Plan and coordinate the daily functions of Quality Management efforts including integration into SHS’s Quality Management Program, Department of Mental Health licensure and certification requirements, Health Resources and Service Administration (HRSA) requirements and The Joint Commission’s National Patient Safety Goals and accreditation standards. Lead specific internal audits to investigate adherence with policies, procedures, and regulatory requirements. This includes thoroughly researching regulations, standards, and policies and then reviewing records, reports, and other relevant sources of information to assess compliance. Assess level of risk associated with non-compliances and provide detailed written reports, tools, data, and education. Assist in the development of action plans and monitor progress on such action plans that result from internal audits or external audit, certification, and accreditation surveys. Develop, annually, a compliance audit schedule delineating the priority areas for review based on level of risk. The level of risk should be based on completed risk assessments and audits. Work to the annual work plan and manage resources such that the work plan is completed in a timely manner. Coordinate the peer review process from acceptance of cases for peer review, facilitating selection of records, preparation of tools, and reporting of results. Serve as a resource to the Director of Compliance and external auditors during site surveys and fulfill all documentation requests. Conduct root cause and failure mode analysis. Assist in the development and revision of policies and procedures that address systemic quality improvement, patient safety/quality of care issues. Assist in monitoring the implementation of best clinical practice guidelines and evidence based practices. Perform other duties as assigned. Education Requirements A Bachelor’s degree in Business Administration, Health Administration, or Social Work. Master’s Degree preferred. Related training and education beyond a Bachelor’s degree may be substituted. Experience & Qualifications Three years experience and skill in utilization of quality management tools, auditing, and development of databases to support quality management activities. Strong research, writing, and report generating skills Experience monitoring quality improvement utilizing Electronic Health Records/Electronic Medical Records. Excellent communication and organization abilities. Experience in health care organization preferred. Working knowledge of the Missouri Code of State regulations, Joint Commission Standards, Centers for Medicare & Medicaid Services guidelines, and Health Insurance Portability and Accountability Act regulations. Benefits: Health insurance Dental insurance Vision insurance Retirement plan Paid time off Flexible schedule Professional development assistance