Behavioral Health Compliance System Manager

position Summary:

The Behavioral Health Compliance System Manager is responsible for supporting and implementing Behavioral Health specific compliance, risk management, and quality improvement activities at Catholic Charities Serving Central Washington. This position works in close collaboration with Behavioral Health leadership to ensure compliance with licensing, certification, contractual, regulatory requirements, and Washington State laws applicable to Behavioral Health programs. The Behavioral Health Compliance System Manager serves as the HIPAA Security Officer for the organization.

Responsibilities:

Behavioral Health Policies and Procedures

• Maintain, review, update, and develop Behavioral Health specific policies and procedures required for licensure, certification, and operations, in coordination with Behavioral Health leadership.
• Ensure Behavioral Health policies align with agency wide compliance frameworks and applicable regulatory requirements.
• Maintain organized and current electronic files of Behavioral Health compliance documentation and policies.

Compliance Concerns, Client Complaints, and Critical Incidents

• Receive reports of Behavioral Health related compliance concerns, client grievances, and critical incidents.
• Coordinate, conduct, and document investigations into reported concerns or incidents in collaboration with Behavioral Health leadership, the Executive Vice President/Chief Operating Officer, or Human Resources when appropriate and dependent upon the nature of the concerns or incidents. Recommend corrective actions to address findings and reduce future risk. Track implementation of corrective actions.
• Ensure appropriate documentation, reporting, and follow up consistent with licensing and contractual requirements.

HIPAA

• Oversee the organization’s HIPAA security program, ensuring compliance with federal and state regulations governing the protection of electronic protected health information (ePHI).
• Lead security risk assessments and vulnerability analyses, identifying gaps and driving remediation planning in coordination with IT and leadership.
• Develop, implement, and maintain HIPAA security policies, procedures, and safeguards aligned with organizational and regulatory requirements.
• Inform the Chief Information Officer and/or other designated IT staff of any data breaches or potential data breaches.

Incident Reporting and Investigation Management

• Manage Behavioral Health incident reporting processes, including data entry, tracking, and documentation within designated systems.
• Monitor trends in incident data and assist with identifying opportunities for quality improvement.
• Support timely review and closure of incidents and related investigations.

Licensing, Audits, and Corrective Action Plans

• Prepare and submit documentation for Department of Health and other needed initial and renewal licensing for individual service sites.
• Assist in preparation for Behavioral Health licensing reviews, audits, and monitoring visits, including coordination of documentation, policies, and records.
• Track Behavioral Health corrective action plans (CAPs) resulting from audits or reviews and assist with documentation demonstrating full implementation.
• Support communication of audit outcomes and corrective actions to appropriate leadership.

Quality Improvement Activities

• Participate in Behavioral Health quality improvement initiatives related to compliance, incident review, and risk management.
• Assist with analysis of incident and audit findings to identify systemic issues and support development of improvement strategies.
• Participate in Quality Improvement/Quality Assurance meetings and assist with documentation and follow up as assigned.
• Conduct an annual review of employee access and permissions to use 3^rd party systems and update as indicated.

Training Management and Support

• Manage and maintain training management system(s) related to Behavioral Health compliance and regulatory training.
• Track completion of required Behavioral Health trainings and support follow up for overdue requirements.
• Assist with coordination and facilitation of Behavioral Health compliance related training for staff and supervisors.

Perform other duties as assigned.

Job Requirements:

Physical Requirements:

This position normally requires the physical demands of standing, walking, bending, lifting, talking, and hearing required to perform job duties. These physical demands are required up to approximately 80% of the time.

Non Physical Requirements:

education

• Bachelor’s degree in Healthcare Administration, Public Health, Behavioral Science, Psychology, Social Work, or a closely related field from an accredited college or university.

experience

• Minimum of two (2) years of experience in healthcare compliance, quality assurance, human services, Behavioral Health, licensing, or a related field required.
• Experience with Behavioral Health licensing, regulatory standards, incident reporting, or quality improvement is strongly preferred.
• Experience conducting audits, risk assessments, and compliance training preferred.
• Experience in behavioral health settings and their unique regulatory and operational environments preferred.

Special Skills

• Strong written and verbal communication skills.
• Ability to work collaboratively with Behavioral Health leadership and multidisciplinary teams.
• Demonstrate integrity, initiative, organizational skills, and sound judgment.
• Proficiency in Microsoft Office applications (Word, Excel) and ability to learn other software systems.
• Ability to conduct thorough investigations and manage sensitive and confidential information with discretion.

Licenses, Registration, or Certification

• Valid Washington State driver’s license and minimum required liability insurance for Washington State
• Must be deemed insurable as determined by Catholic Charities’ insurance liability provider

Employment is conditional upon:

• Being cleared by criminal background check and fingerprinting when required

Work Schedule: Monday-Friday, 8:00am – 5:00pm
Wage Range: $32.00-$39.00 per hour, depending on education & experience
Benefits:

• 13 paid holidays, 12 days of vacation, 12 days of sick leave per year
• Health insurance including medical & prescription coverage, with optional dental and vision insurance plans. Majority of premiums paid by Catholic Charities
• Retirement 403(b) Plan: employee contributions commence upon employment; Catholic Charities contributes 2% of monthly income and matches up to 4% of employee contributions following 6 months of employment
• Basic Life Insurance paid 100% by Catholic Charities
• Flexible Spending Account eligibility following 6 months of employment
• Education Assistance Program reimbursing up to $5,250 per year for approved continuing education after 6 months of employment
• Additional voluntary insurances including supplemental life, accidental death & dismemberment (AD&D), critical illness, long term disability, accident, and ID theft
• Employee Assistance Program includes 3 counseling sessions per year, legal consultations, financial coaching, and other wellbeing tools
• Annual longevity awards begin at 5 years of employment

It is the practice of Catholic Charities to ensure equal employment opportunity without discrimination or harassment on the basis of race, color, national origin, sex, age, disability, citizenship status, marital status, creed, genetic predisposition or carrier status, sexual orientation, gender expression, or any other characteristic protected by applicable law. Applicants from underrepresented backgrounds are encouraged to apply. We gladly offer reasonable accommodations to individuals with disabilities to support participation in the hiring process and employment.