TRC 1000x200

TRC - Quality Improvement Compliance Officer/Privacy Officer

200 Dunham Ave, Jamestown, NY 14701, USA Req #4178
Wednesday, November 23, 2022
The Resource Center has been providing services to persons with disabilities in the Chautauqua County area since 1958. From our humble beginnings as a gathering of parents and concerned citizens who wanted to provide educational and training opportunities for persons with developmental and intellectual disabilities, The Resource Center has grown into a comprehensive agency providing services to thousands of persons with all types and levels of disabilities.

The Resource Center is the largest non-governmental employer in Chautauqua County with more than 1,300 employees on its payroll.

The mission of The Resource Center is to support individuals with disabilities and other challenges in achieving maximum independence, contributing to their community, experiencing lifelong growth, and enjoying quality of life.

Quality Improvement Compliance Officer/Privacy Officer

RESPONSIBLE TO:Assistant Executive Director QA/QI


Plans, coordinates and implements quality management and quality improvement programs. Monitors and provides assistance with quality assurance and compliance functions. Provides consultation and direction to ensure programs and services are implemented at the highest standards with a focus on compliance, ethics, risk and safety. Contributes to the fulfillment of the agency’s mission by planning, designing, implementing and maintaining system-wide compliance and quality improvement plans. Coordinates and facilitates agency-wide compliance with regulatory standards, legal requirements, agency policies and procedures and standard practices. Ensures policies and procedures are monitored and updated to include regulatory changes. Ensures that issues related to risk management, regulatory compliance, plans of corrective action and opportunities for services improvement are identified and corrections are implemented.

Analyzes causative factors and works to prevent and/or reduce re-occurrences of risk and/or non-compliance events. Identifies trends and systemic issues and coordinates with programs to address as proactively as possible, to remedy compliance issues on an Agency-wide basis.


Provide direction to executive management staff to ascertain adherence to quality standards, and opportunities for service or operational improvement, prevent and/or reduce liability to the agency. Oversees the implementation and compliance with incident management standards.


Identifies strategies to ensure risks are identified and reduced, acceptable policies and procedures are followed, and established standards are met.

Serves as the designated official responsible for the agency’s HIPAA privacy compliance program. Oversees the development, implementation, maintenance and compliance with compliance program standards.


·Ability to read, analyze and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries

·Ability to define problems, collect data, establish facts, and draw valid conclusions

·Ability to maintain and ensure confidentiality, as this position is exposed to highly confidential information, which if inappropriately revealed, would be in opposition to company policy, professional ethics and integrity

·Ability to adapt and respond to a complex, fast paced, rapid results oriented environment

·Strong work ethic built on a foundation of being proactive and teamwork

·Ability to navigate ambiguity with the aid of structured problem solving techniques

·A positive attitude; ability to work hard, have fun, and operate efficiently in a fast paced work environment

·Comprehensive knowledge of Health Care regulatory codes, OMIG and OPWDD standards, Generally Accepted Accounting Principles, Generally Accepted Auditing Standards, Federal and NYS Taxation regulations

·Strong working knowledge of HIPAA regulations and standards required

·Ability to work with TRC management, Board of Directors, and external auditors

·Strong oral and written communication skills

·Ability to communicate the need for change and possess skills in personal diplomacy

·Ability to use analytic software/programs such as Excel, Word and Powerpoint

·Excellent organizational skills and the ability to synthesize multi-source data for purposes of tracking and analysis

·Ability to supervise the work of others

·Ability to work under general direction, according to agency procedures


Bachelor’s degree required, advanced degree preferred

Five years of closely related experience, to include demonstrated leadership

Valid NYS driver’s license

Ability to travel for work or equivalent accommodations required

Physical condition commensurate with the demands of the job


The required leadership competencies as identified using Lominger Career Architect include, but are not limited to:

Functional/Technical Skills, Timely Decision Making, Action Oriented, Intellectual Horsepower, Priority Setting, Organizing, Integrity & Trust, Problem Solving, Command Skills, Comfort Around Higher Management, Ethics & Values, Dealing with Ambiguity, Strategic Agility, Interpersonal Savvy, Composure, Dealing with Paradox, Conflict Management, Managerial Courage, Political Savvy

The successful incumbent will place adequate emphasis on the following competencies:

Courage (i.e. Conflict Management, Managerial Courage), Organizational Positioning(i.e. Political Savvy), Strategic(i.e. Dealing with Ambiguity, Strategic Agility), Personal & Interpersonal (i.e. Interpersonal Savvy, Composure, and Dealing with Paradox)


1. Oversee and monitor the implementation of the Compliance Plan

2. Report on a regular basis compliance issues and the status of the Compliance Plan and key agency risk areas.

3. Assists in establishing standards for compliance, giving specific guidance to management and staff as appropriate.

4. Monitor changes in relevant legal requirements through consultation with Program Directors and review of fraud alerts, program memoranda, and other relevant publications issued by federal or state government agencies, including OPWDD, DOH, OIG, CMS and OMH to identify present or emerging risks.

5. Develop, coordinate and document compliance related educational and training programs.

6. Seek to ensure employees are aware of and comply with the Compliance program, applicable fraud and abuse laws, HIPAA standards and privacy standards.

7. Identify trends,, systemic issues, regulatory compliance issues and other issues of concern for QA/QI and/or Compliance discussion and deliberation.

8. Ensure agency risks are identified, assessed, monitored and mitigated.

9. Initiate and ensure mitigation of risk regarding HIPAA standards.

10. Provide guidance to all departments to ensure compliance with specific privacy requirements

11. Investigate allegations of non-compliance and assist in developing appropriate actions to resolve and reduce potential for recurrence.

12. Provides trending analysis to monitor regulatory compliance, quality assurance and quality improvement and to provide information to improve decision making and strategy execution.

13. Collaborates with AED QA/QI to ensure overall agency compliance with regulatory requirements and standards of practice.

14. Responsible for ensuring fiscal stability through the development of operational budgets, with responsibility for ongoing monitoring of expenses and revenues.

15. Responsible for ensuring the development of Outcomes and Performance Targets relative to agency quality improvement and ensures the implementation and tracking of relevant Performance Targets.

16. Represents department’s programs and services at various meetings and committees within and outside the agency in order to facilitate and maintain cooperative relationships, as needed or assigned.

17. Designs and implements a process to verify that recommendations are acted upon and deficiencies are remedied and ensures practices are in place to maintain compliance.

18. Ensure the required reporting of violations to duly authorized enforcement agencies.


Responsible for providing administrative supervision to assigned Compliance staff including but not limited to:

a. Hiring, firing, discipline, performance evaluation, in-service education and training, and ensuring that there is an adequate number of staff to fulfill assigned responsibilities.

b. Oversees all aspects of the workforce, including timely completion of new hire paperwork, disciplinary actions and other personnel related matters.


Performs all other related duties as assigned by the Executive Director or AED for QA/QI.


Internal Accesses:

Badge access to Dunham 24/7 with alarm code

Email (internal and external)

Help desk platform

Ultipro (Human Resources Information System)

Internet- Google Chrome, Explorer, YouTube, Social Media Browsing

Shared drives- TRC drive, QA/QI drive (Compliance), Residential P&P, Clinical

Services, Rehab and Supported Employment, Risk Assessment Folder, BHCC

Kronos (time and attendance system)

Relias (Training Management System)

Therap (Electronic Documentation Platform)

Basecamp (Project Management Platform)


Agency Policies

HRIS (Human Resources Information System)

ARM (Advanced Requisition Management)

Allscripts (Electronic Health Records)- PM, Clinical Module

Dentrix ( (Electronic Health Records-DENTAL)

Anasazi (Electronic Health Records-MENTAL HEALTH)


External Vendor Access

ARC NY-Chapter Reporting System, Chapter Portal

NIMRS Token (RSA Software)

Zebu Compliance-Exclusion Screening


3/19, 11/22

Executive Support


Grade 21, Exempt

Support—Grade 27, Exempt

____________________________________________ _______________

Employee Signature Date

____________________________________________ _______________

Supervisor Signature Date

The Resource Center is an equal employment opportunity employer and will not discriminate on the basis of race, color, creed, religion, sex, sexual orientation, gender identity, national origin, age, marital status, citizenship status, military status, domestic violence status, predisposing genetic characteristics or genetic information, physical or mental disability, any other category protected by law, or any other non-job related characteristic. As needed, The Resource Center will provide reasonable accommodations for disabilities to employees and applicants whenever such accommodation would not create an undue hardship or a safety concern in the conduct of TRC’s operations.

Other details

  • Job Family TRC - Active - PFL/DBL Eligible
  • Pay Type Salary
Location on Google Maps
  • 200 Dunham Ave, Jamestown, NY 14701, USA