Supervisor of Compliance and QI

**Please note:** *Ottawa County Community Mental Health is currently transitioning to an independent authority. As of October 1, 2026, this position will be part of the Ottawa County Community Mental Health Authority.* Under the direction of the CMH Chief Operating Officer, this individual serves two essential duties: 1. COMPLIANCE and QI Supervisor: In this role, the Compliance Manager designs, implements, and supervises continuing compliance of the organization with local, state, and federal standards. 2. HEALTHINFORMATION Supervisor: Ensures that all consumer records (paper and electronic) are maintained in accordance with Ottawa County, MDCH, and CARF standards and incompliance with the provisions of HIPAA and other federal standards (e.g. BBA). This is a full-time, benefited position working out of the James Street Complex located at 12265 James Street, Holland, MI. Typical working hours are Monday - Friday, 8:00 a.m. to 5:00 p.m. **The** **essential** **functions** **of** **this** **position** **include,** **but** **are** **not** **limited** **to,** **the** **following:** **Compliance Manager:** 1. Monitors compliance with established agency, county, PIHP, state, and federal standards across the network of providers. 2. Coordinates the development/implementation of the compliance program to ensure compliance with the standards established by the Michigan Mental Health Code (PA258of1974), Michigan Department of Health and Human Services (MDHHS) rules and regulations, the Ottawa County Mental Health Board, the Commission on Accreditation of Rehabilitation Facilities (CARF), and federal standards (e.g. HIPAA, BBA, DRA, OIG, 42 CFR Part 2). 3. Prepares, coordinates and acts as the primary liaison and lead during surveys and audits from the PIHP, MDHHS, and CARF. Ensures completion of Corrective Action Plans and implementing Quality Improvement Activities for the organization. 4. Develops, supervises, and participates in the implementation of standard operating policies and procedures for the operation of community mental health services. 5. Investigates, documents, reports, and develops appropriate responses and protocols to prevent future occurrences of medication errors, injuries to consumers and staff, infection control and serious communicable disease incidents, biohazard incidents, weapons on-site, and other critical incidents and sentinel events. 6. Investigates, documents, reports and monitors billing issues, documentation issues and Fraud, Waste and Abuse reports. 7. Advises, participates in, and reports serious compliance violations to the CMH Compliance Committee. 8. Collaboratively works to ensure that all staff comply with training and continuing education requirements for maintenance of licenses and accreditation. 9. Collaborates with community mental health care providers to ensure proper adherence to Michigan Mental Health Code and federal and MDHHS rules and regulations in the delivery of mental health services. 10. Recommends Standards of Conduct, related policies, and procedures. 11. Monitors corporate-wide compliance plan for periodic updates when needed. 12. Oversees compliance investigations with law enforcement, corporate counsel, medical director, PIHP, human resources, and/or any other appropriate party. 13. Recommends reporting channels (e.g. Hotline) for use without fear of retaliation. 14. Maintains a working knowledge of relevant issues, laws, and regulations. Health Information Manager: 1. Designs, develops, implements, and maintains uniform policies and procedures for the documentation and maintenance of patient health information stored in all modalities (images, paper, and electronic). 2. Develops and implements quality assurance and quality control protocols for health information and case data management. 3. Thorough working knowledge of the Electronic Health Record. 4. Develops proposals and recommendations to apply innovative technological solutions to health information processing and fi…