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.