Director of Compliance, Quality, & Risk Management
16 days ago
Rochester
Rochester, Syracuse or Buffalo, NY In support of PPCWNY’s mission, the Director of Compliance, Quality & Risk Management (CQRM) provides senior-level leadership for the design, implementation, and oversight of an integrated, agency-wide compliance, quality, and risk management program. Working collaboratively with clinical and administrative leadership, this role ensures organizational adherence to Planned Parenthood Federation of America (PPFA) standards, internal policies, and all applicable federal, state, and local regulatory requirements. The Director promotes a culture of accountability, transparency, patient safety, and continuous improvement while strengthening organizational readiness, resilience, and governance. This role requires routine travel to all PPCWNY health centers to provide training, support audit readiness, and ensure consistent implementation of compliance and quality standards. Essential Functions Compliance, Policy & Regulatory Oversight • Leads and maintains an effective healthcare compliance program aligned with Office of Inspector General (OIG) guidance, PPFA standards, and applicable federal, state, and local regulations., • Serves as administrator for the organization’s policy management system, overseeing policy development workflows, version control, approvals, distribution, staff access, and attestation., • Develops, reviews, and maintains compliance-related policies, procedures, and protocols, including HIPAA, HITECH, CLIA, NYS Article 28, Title X, OMIG guidance, and records retention requirements., • Provides organizational oversight of OSHA compliance, including workplace safety standards, exposure control, hazard communication, required training, and corrective action coordination., • Serves as the enterprise lead for all internal and external audits, inspections, surveys, and reviews, including regulatory, funder, payer, PPFA, OSHA-related, and accreditation processes., • Coordinates audit planning, document production, staff preparation, on-site logistics, and audit responses across departments and health centers., • Maintains continuous audit and survey readiness through routine monitoring, mock audits, and compliance validation activities., • Tracks audit findings, corrective action plans, responsible parties, and timelines to ensure timely resolution and sustained compliance., • Partners with leaders across Patient Services, Finance, Revenue Cycle, Human Resources, Information Technology, Development, Legal, and Grants & Programs to integrate compliance, quality, audit readiness, and risk management practices into daily operations., • Provides consultative guidance to departments on regulatory interpretation, risk identification, and implementation of practical, sustainable compliance solutions., • Provides direct supervision and performance management for the Clinical Quality & Safety Manager, ensuring quality, patient safety, compliance, and audit-readiness activities align with organizational and regulatory priorities., • Partners with clinical leadership to ensure quality assurance, patient safety initiatives, and performance improvement activities meet PPFA, regulatory, and accreditation standards., • Leads enterprise-wide risk assessments addressing clinical, operational, financial, privacy, audit, safety, and reputational risks., • Maintains the organizational risk register and prioritizes risk mitigation strategies., • Serves as administrator or advanced user of compliance-related systems and tools, including the policy management platform and Smartsheet., • Uses Smartsheet to track audits, corrective actions, training completion, policy reviews, risk mitigation activities, and CQRM work plans., • Develops dashboards and reports to support oversight, prioritization, and executive-level decision making., • Designs, delivers, and oversees compliance-, quality-, audit-, HIPAA-, OSHA-, and Infection Prevention-related training programs for staff across the organization., • Establishes and maintains a standardized new-hire compliance and safety onboarding program, ensuring timely completion of required trainings and policy acknowledgements., • Provides in-person and on-site training at all PPCWNY health centers, as needed, to support staff education, regulatory compliance, and quality improvement efforts., • Ensures training completion, effectiveness tracking, and documentation in support of regulatory, audit, and accreditation requirements., • Serves as an independent advisor to executive leadership and the Board of Directors on compliance, quality, audit outcomes, workplace safety, and enterprise risk., • Chairs the CQRM Committee and the 340B Oversight Committee, setting agendas, guiding cross-functional participation, and ensuring accountability for follow-through., • Provides regular and ad-hoc reporting to executive leadership and designated Board Committees., • Has authority to request records, data, and staff participation necessary to support audits, investigations, and regulatory or funder reviews., • Evaluates vendors, contractors, and affiliates for compliance with organizational, regulatory, and audit requirements., • Integrates health equity, nondiscrimination, and culturally responsive care principles into compliance, quality, audit, and risk management activities., • Ensures sustained organizational readiness for regulatory, funder, payer, PPFA, OSHA, and accreditation audits, including timely resolution of findings and prevention of repeat deficiencies., • Ensures policies, procedures, and supporting documentation remain current, accessible, and consistently applied across all health center and administrative locations., • Demonstrates continuous improvement in quality, patient safety, and enterprise risk mitigation through data-informed oversight and corrective action., • Ensures effective committee governance with clear agendas, documentation, and follow-through on identified actions. Applicants must possess the following qualifications (or equivalent combination of education and relevant experience): Education • Minimum of 5 years of progressive experience in healthcare compliance, quality, and/or risk management., • Experience with accreditation, regulatory oversight, audits, and healthcare compliance programs required., • CPHQ, CHC, CHPC, PMP, Lean Six Sigma, or equivalent, • RN, NP, or PA strongly preferred Knowledge, Skills, & Abilities • Strong knowledge of healthcare regulatory requirements including HIPAA, OSHA, CLIA, Title X, NYS Articles 27-F and 28, OMIG guidance, and PPFA standards., • Proficiency with Microsoft Office and Smartsheet., • Strong analytical, organizational, leadership, and communication skills., • A commitment to PPCWNY’s mission, vision and values along with a commitment to the goals of PPCWNY is essential Working Conditions • Standard office and health center environment, • Well-lit/ventilated Physical Requirements • Possess sufficient mobility to perform the Essential Functions listed in this Job Description with or without an accommodation, • May experience visual fatigue working at computer with potential extended periods of sitting, • Ability to travel to all agency locations as assigned Work Schedule This is a full-time, 40 hour a week, position; regular schedule will be Monday – Friday with occasional evenings and weekends. Benefits & Compensation At PPCWNY, we're committed to equitable compensation practices and transparency. In alignment with these efforts, the pay for this position ranges from $106,766.40–$136,427.20 annualized. Actual compensation will be determined by experience and other factors permitted by law. In addition to competitive compensation, PPCWNY offers an extensive benefits package with generous Paid-Time-Off, 10 paid holidays, affordable medical, dental, and vision options, Health Savings Account or Flexible Spending Account, 401(k) with match, and much more! Planned Parenthood of Central and Western New York is an equal opportunity employer.
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