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Director of Quality Assurance and Compliance. 

About the Organization Catholic Charities, Diocese of Trenton is a faith inspired non-profit organization, mission-driven, family-friendly, and passionate about services to our communities. We offer a wide variety of exciting career opportunities in the areas of Direct Care, Clinical, Fundraising, Human Resources, IT, Finance, Marketing, and Nursing. When you join us, you can expect a true focus on work-life balance, rewarding career, competitive salaries, and comprehensive benefit programs. Some of our benefits include: generous paid holidays, vacation, and sick time; Employee Assistance Program, excellent health & pension plans; Public Student Loan Forgiveness program; and wide array of training and staff development opportunities to earn on-site CEUs. Catholic Charities is an Affirmative Action / Equal Opportunity Employer, fostering a diverse and inclusive environment for staff as well as for people seeking assistance.

To learn more about the agency, please visit our website at: For frequently asked questions, please click here:  
Req Number ADM-23-00006  
Location CAS - Access Center (Lawrenceville, NJ)  
Full-Time/Part-Time Full-Time  
Number of Openings 1  
Category Administration  

Job Summary:

              The Director of Quality Assurance and Compliance is responsible for the overall development, implementation and management of the Agency Quality Assurance and Compliance Program.  Responsible for the maintenance of and adherence to organization’s policies and procedures covering the privacy and access to client clinical information licensing and accreditation, in accordance with federal and state laws and agency requirements.   Coordinates and monitors all compliance activities and programs and quality improvement activities.   

Duties and Responsibilities:


Overseeing and monitoring the implementation of the compliance programs:  including privacy and access to client records, and serves as agency Ombudsperson for client satisfaction, perception of care inquiries.

Works with legal counsel and leadership, key departments and committees to ensure the organization has and maintains appropriate privacy and confidentiality consent, authorization forms and information notices and materials reflecting current organization and legal practices and requirements.

Periodically updates policies and procedures to maintain compliance with laws and  regulatory authorities.

Coordinates and facilitates annual review of agency-wide policies and procedure manuals (AP, HP, and CP –Administrative, HIPAA/HITECH and clinical) with summary reports for the annual review by the Strategic Planning Committee of the Board and the Board of Trustees. Developing policies and programs that ensure protocol are in place and staff have options to report suspected fraud and other improprieties without fear of retaliation.

 Complete False Claims paperwork (Section 6032 Federal Deficit Reduction Act) for review and sign off by the Executive Director for submission to the Office of the State Comptroller, Medicaid Fraud Division on a yearly basis.

Investigates matters related to compliance in accordance with legal guidance and agency policy and procedure.  Prepares reports and recommendations in accordance with directives from legal leadership. 

Investigates client complaints with Human Resources and legal as necessary to resolve concerns and improve quality of care. 

Assists Leadership and designees coordinating internal compliance reviews. 

Develops and implements training programs regarding compliance. 

Manages incident reporting process to ensure proper and timely reporting

 Agency-wide Accreditation

Responsible for the agency-wide accreditation by maintaining up-to-date on accreditation standards/systems/processes in order to maintain and exceed accreditation expectations.

Provides educational training, both group and individual, to ensure staff knowledge with the accreditation standards.  Complete mock surveys as requested.

Develops, coordinates and facilitates all accreditation site survey review documentation –both documentation for the accreditation portal as well as on site documentation. 

Develops accreditation site review schedule to facilitate the effective and efficient use of reviewers.

Completes the yearly Maintenance of Accreditation report yearly in order to maintain accreditation.

Reports all critical incidents and records in accreditation portal. 

  Licensing , Medicare/Medicaid Reviews

Responsible for the coordination and facilitation of all licensing reviews. 

Provides guidance and training to facilities and security staff for compliance and licensure preparation

Provides education and training to departmental staff as it relates to licensing regulation compliance.

Initiates on site reviews of program sites prior to licensing visits to ensure compliance.

Escorts licensing review team from site to site in order to assist reviewers in understanding our programs/sites. 

Coordinates and completes the Plan of Correction for Licensing.

Facilitates Medicare/Medicaid reviews and coordinate and completes the plan of correction.    

 Quality Improvement

Responsible for the direction of the agency -wide Quality Improvement Program in accordance with agency’s mission, accrediting/licensing requirements and agency’s strategic plan.

Chairperson of the Agency-wide Quality Improvement Committee as Quality Improvement subcommittees. 

Provides training on Logic Model/PDSA/CQI as needed.

Compiles and presents quarterly QI/Logic Model/PDSA reports to the Strategic Planning committee of the board for presentation to the Board of Trustees. 

Serves as secretary to the Consumer Advisory Committee. 

Coordinates, completes and uploads CCUSA Program Detail Report, Core Services Report and CLINIC Immigration reports yearly.

 Utilization Management

Supervises Utilization Review staff as it relates to data collection, report generation and timely reporting

Supervises and directs periodic audits as needed to identify areas in need of improvement.

  Risk Management and Safety

Manages Risk Management Program by reviewing all incident reports and flagging and monitoring those that need additional action steps and rapid cycle PDSA

Manages risk management insurance program serving as liaison to the Chancery on insurance matters and renewals.

Via incident reporting system, notify and/or send reminder to directors when case reviews are needed. 

Report all critical incidents to COA. 

Chairperson of the Agency Safety Committee as well as the Mercer Campus Safety Subcommittee. 

Develop agenda for the Safety Committee and utilizes Risk Management Incident report to develop PDSA and other actions steps needed by Maintenance/Programs. 

Investigates incidents and responds to any OSHA complaints. 

Serves as member COVID workgroup to address pandemic related issues

Health information Management and Reporting

Manages EHR Clinical system to ensure compliance and reporting functionality

Oversees training resources for clinical modules of EHR

Assists with reporting functionality and training of HER

Ensures EHR maintains compliance with level of care licensing standards

Conducts system audits to ensure proper functionality of EHR

Job Relationships:

Reports to Associate Executive Director of Operations

Works in close collaboration with the Service Area Directors and their designees, Leadership and their designees and support agency committees as appropriate.

Maintain professional relationship with licensing and accrediting agencies and serves as a liaison between the programs and the licensing/accrediting bodies.


Position Requirements

Master’s degree in Healthcare required

Clinical License preferred

Previous Medicare/Medicaid operations and HIPAA experience required

Proficiency with MS Operating System, Electronic Health Record Systems, required. Experience with BI and data dashboards a plus

Excellent oral and written communication skills

Strong understanding of licensing and regulatory protocols for Mental Health (Adult and Child) and Substance Use Disorder Programs required. 

Knowledge of certification process for CCBHC preferred

Joint Commission experience a plus



Exempt/Non-Exempt Exempt  
Weekly Work Hours 40  
Proposed Salary $137 - $145K  
Schedule TBD 

This position is currently accepting applications.

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