Catholic Charities Community Services of New York Associate Director of QI, Staff Development & Compliance in New York, New York


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Associate Director of QI, Staff Development & Compliance

Location: New York, NY

FLSA Status: Full Time, Exempt

Classification: Professional

Department: Beacon of Hope Office: Manhattan

Reports to: Division Director

Supervisory Responsibilities: Yes No X

Summary: The Associate Director will have immediate oversight of all areas of Beacon of Hope House. As this position is Division-wide in scope, it is part of the executive management level of the Beacon of Hope House (BoHH). In addition, this position will be responsible for developing an agency-wide QI protocol for CCCS programs.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

  1. Cooperative working relationship with all program and operations staff within the BoHH division and also including, but not limited to the Division Directors, Program Directors, and their direct reports, as well as with various department heads and/or associates within Catholic Charities Community Services, generally.

  2. Act as a liaison with external agencies, associations, vendor’s, etc, facilitating collaboration and education regarding BoHH programs and services.

  3. Perform other administrative and/or clinical duties as directed by immediate supervisor(s).

  4. Direct supervision of the Supervisor of Quality Improvement, Staff Development and Compliance for BoHH.

  5. Direct responsibility to ensure compliance readiness and an internal system of quality controls and reporting of same to all BoHH Directors and Division Director.

  6. Responsibility for oversight of the BoHH Electronic Health Record (EHR) System, including all executive functions and liaison with the EHR vendor.

  7. Oversight of the Supervisor of QI, Staff Development, and Compliance in conducting:

  • Ongoing audit of charts, ensuring timely input of data into the EHR, developing procedures for accountability and the improvement of these records.

  • Utilization Review in licensed housing, including but not be limited to reviewing each client record and overseeing UMR meetings, minimally once a year.

  • Review of Medicaid Billing, including final review of all documentation before billing, and collaboration with CCCS Fiscal Department and Program Staff to resolve client issues as they impact the Medicaid billing process.

  • Utilization Review and billing of Managed Care Organizations (MCO) for HCBS services, including final review of documentation before billing, and collaboration with CCCS Fiscal Department, applicable external vendors and HCBS Program to resolve issues that impact the MCO billing process.

  1. Responsibility for peer audit reviews of all BoHH programs, to include completion of a plan of correction and working with key staff on completing plans of corrective action.

  2. Responsibility for the Incident Review Committee and any other committees as assigned by the Division Director.

  3. Assist in preparation for, participate in and follow-up of government and other audits.

  4. Possibility of a part-time role to begin the process of developing a QI protocol for CCCS programs. This can include file reviews, client satisfaction surveys, incident and complaint review processes, a client grievance process, and other approaches as warranted.

  5. In collaboration with the Supervisor of Quality Improvement, Staff Development, and Compliance, develop an annual BoHH staff training schedule which is reflective of the needs of operations staff. Plan and carry out the training in consultation with the Division Director.

  6. Develop, implement and update policies, procedures and practices designed to ensure compliance with the requirements of the Corporate Compliance Plan and with applicable state and federal laws and regulations and third party payer requirements.

  7. Direct internal audits to monitor the effectiveness of BoHH’s compliance standards and conduct compliance assurance monitoring of potential compliance risk areas. Report on identified weaknesses and incorporate the development of mitigating actions into future work plans.

  8. Coordinate, develop and participate in the education and training program for Board members, management, staff and contractors regarding the Corporate Compliance Plan, Policies, and applicable state and federal laws and regulations.

  9. Insure the maintenance of a reporting system and respond to concerns, complaints and questions related to the Corporate Compliance Plan.

  10. Investigate and act on issues related to compliance in consultation with the Division Director of BoHH and the Executive Director of CCCS and implement corrective actions accordingly.

  11. Act as a resourceful leader regarding regulatory compliance issues.

  12. Maintain and establish policies and procedures as they relate to the applicable federal and state privacy and security laws and regulations.

  13. Establish and administer a process for receiving, documenting, tracking, investigating and taking action on all complaints concerning BOHH’s HIPAA privacy policies and procedures.

  14. Oversee and ensure delivery of privacy training and orientation to all employees.

  15. Maintain current knowledge of applicable federal and state privacy laws.

  16. Work with all organizational personnel involved with any aspect of release of protected health information.

Position Type and Expected Hours of Work:

This is a full-time position. Days and hours of work are generally 9:00 AM to 5 PM Monday - Friday. Additional hours may be required to meet program deadlines, or client needs.

Working conditions and physical demands required:

The demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

  • Travel for home visits, outreach and/or escorting clients at least 60% of the time using reliable transportation, traversing streets, ascending/descending stairs, and exposed to outside weather conditions.

  • Assess and work in varied home environmental conditions, possibly including vermin/bedbugs.

  • Traverse neighborhoods that may require a high level of alertness and awareness of surroundings.

  • Work with clients who require consistent and comprehensive support, some under potentially stressful conditions.

  • Remain in a stationary position at a work station and use a computer approximately 40% of the time.

  • Frequently sit for long periods attending meetings.


Education and/or experience required:

  • Masters Degree in Human Services – Required

  • Five (5) years of progressively increased responsibility in an organization providing services to the mentally ill or other vulnerable populations.

  • Experience with public agency funding and regulating community residence programs and other services for mentally ill adults.

Skills, Licenses, and/or competencies required:

  • Strong organizational skills required.

  • Excellent written and verbal communication skills also required.

  • This position requires a high degree of independence and a capacity to work effectively in a fast-paced and constantly changing environment.

  • Health Care Compliance Certification