Compliance and Program Audit Specialist

 Zepf Center has been serving the Lucas County community for nearly 50 years. We are the leading provider of behavioral health and substance use disorder services in Northwest Ohio. Services include adult and child psychiatric, substance abuse, case management, residential, Crisis Care, and therapy programs, as well as career development and wellness services. Zepf Center also offers primary care medical services to our patients to contribute to their continuum of care. Zepf Center is a trauma-informed agency and environment for both patients and staff. 

We are currently seeking a full-time Compliance and Program Audit Specialist.  The purpose of this position is to serve as an integral member of the Compliance department team to educate the agency on local, state, and federal regulations, create systems of accountability, and report agency performance. This person will monitor patient and stakeholder satisfaction; maintain the compliance calendar and provide reminders to the compliance team and other agency personnel when regulatory and accreditation items are due; coordinate and schedule compliance audits, Health and Safety requirements, regulatory audits, and accreditation site visits; facilitate organizational communication of audits, results, and action plans. 

Essential Duties of this position include but are not limited to:

• Responsible for completing a daily expectation of chart reviews on open and closed cases, considering client care, standards, and procedure compliance.
• Evaluate documentation patterns and collaborate with department leaders in training, clinical, and compliance to create and implement necessary action plans
• Serve as point person for the department in following up with clinicians and managers who have not submitted necessary training or compliance documentation.
• Schedules and supports internal Audits in conjunction with the Compliance Manager
• Performing site visits to Zepf locations for policy conformance, documenting findings, and reporting to supervisors for correction or modification.
• Works with compliance team and other staff members to prepare for regulatory audits and accreditation site visits to ensure accuracy to limit agency financial loss.
• Assists in maintaining required documents needed for regulatory and accreditation entities are up to date and readily available for unannounced site visits.
• Initiates and works with Compliance Manager and other staff members in the agency to ensure applications are completed accurately and sent to the regulatory entities timely.
• Identifies items needed for the site visit, works with staff members to identify who is responsible for missing items. Sets up Outlook reminders to ensure items are received timely.
• Informs the Sr. Compliance Director, and/or other supervisors when items are not received on time.
• Participates in agency-wide projects and staff development; carries out policies and procedures of agency.
• Works with the Compliance Department and Health Information Technology (HIT) team and others to analyze data and complete required agency and external reporting requirements.
• Supports Clinical Coordinator in monitoring and tracking corrective action plans, audit recommendations, and quality improvement projects to ensure implementation, effectiveness, and completion.
• Facilitates post-audit communication/debriefings to identify areas for improvement based on feedback received.
• Coordinates formal corrective action plans and/or quality improvement projects as needed.
• Monitors and communicates with staff as needed to ensure follow-up action is taken to ensure Corrective Action Plans (CAP)s and Quality Improvement Plans (QIP)s are fully implemented and followed through until completed.
• Assists leaders in developing and implementing corrective action plans related to metrics set forth by the agency or external auditing bodies
• Works as the Client Advocate to triage and follow-up timely on patient rights and grievances.
• Attend Department Team Meetings to discuss KPIs
• Lead QI meetings and complete KPIs for meetings
• Maintains necessary documentation related to complaints and grievances and completes year end reporting.
• Works with compliance team and the agency Training Director to provide training to meet regulatory and accreditation standards.
• Identifies annual training needs and provides information to the Training Director to set the calendar.
• BLS certified and Lead Courses
• Prepares presentations and provides training as required during new hire orientation and to departments within the organization.
• iResearches materials to incorporate into the training.
• Creates training materials or works with others to create.
• Monitor Medical Lines for Client Refills and Medicine Concerns
• Communicates with people outside the organization, representing the organization to customers, the public, government, and other external sources.
• Fills in for other members of the compliance team to ensure agency needs and regulatory requirements are met. Stays up to date on state and federal compliance regulations along with local clinical care standards
• Identifies and assesses significant business risks through managing and reporting compliance breaches and exposures. Assist with compliance investigations stemming from reported incidents
• Supporting various departments by collecting and coordinating compliance data Ensuring complete, accurate and timely data to all correct parties
• Assist the agency with Sanctuary implementation, advise on trauma-organized guidelines, agency and department with privacy functions; HIPAA, risk assessments and staff/client updates
• Perform other duties as assigned.

Specific/Individual Competencies:

• High attention to detail and able to draw conclusions and guidance based on regulations Ability to work independently as well as cooperatively within teams
• Ability to write clear, concise, accurate and grammatically correct documents/reports. Use of discretion regarding sensitive and confidential information
• Ability to plan and organize time and tasks to meet timelines; ability to prioritize and adapt quickly to changing needs. Ability to maintain office equipment
• Superior customer service skills; ability to relate well with all levels of staff and consumers Flexible
• Incorporates HIPAA, Ohio Law, and 42 CFR Part 2 compliance and training as needed
• Knowledgeable of OhioMHAS regulations and CARF standards. Perform complex and critical analytical explanations of records/data communicate clear and concise, orally and written
• Ability to work on multiple projects with strict deadlines Establish and maintain effective working relations Knowledge of Medicare/Medicaid regulations and guidelines

Organizational Competencies:

• Understands and articulates the agency’s core mission, vision, and strategic objectives.
• Dedicated to the principles of the Sanctuary Model, utilizing the seven commitments as a guide to creating a safe and non-violent environment for clients and staff.
• Familiar with and adheres to relevant policies and procedures to ensure compliance and operational effectiveness.
• Demonstrate proactive and effective leadership to address client needs promptly and efficiently.
• Works closely with coworkers and clients to create a seamless and integrated care process.
• Ensures that all services are tailored to meet the specific needs and expectations of clients.
• Maintains a high standard of professional behavior in all interactions with clients and colleagues.
• Exhibits integrity, accountability, and respect in the workplace, fostering a positive and productive organizational culture.
• Actively participates in team activities, fostering a collaborative environment.
• Supports colleagues and contribute to group efforts to achieve shared goals and enhance service delivery.
• Upholds the agency’s code of ethics and professional standards in all practices.
• Demonstrates ethical decision-making and accountability in both individual and team contexts

• Bachelor's degree in social services, business, or related field required Master degree preferred
• Experience with HIPAA compliance and 42 CFR Part 2 knowledge preferred
• Previous experience working with an electronic health record (EHR) system. SmartCare Preferred Experience with Microsoft office products
• High computer proficiency
• Valid driver's license and the ability to be covered under the agency's commercial car insurance. Proof of car insurance for the vehicle that will be driven in the course of business.

Those eligible to drive company vehicles must have a valid driver's license and be eligible for coverage as defined by the agency commercial insurance carrier. Those who drive personal vehicles in the course of business must be able to provide proof of insurance.