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Job Description
Position Title:
Program Manager -
Compliance & Quality Management Reports To:
Chief Executive Officer (CEO) Position Summary The Program Manager - Compliance & Quality Management is responsible for providing organizational leadership and oversight of compliance, quality assurance, licensing requirements, investigations, and operational performance across all LNL programs. This position serves as a key member of the leadership team and works directly with the CEO to ensure the organization maintains full compliance with all applicable state, federal, and regulatory requirements. The successful candidate will serve as the organization's Certified Investigator, oversee quality management initiatives, monitor performance-based contracting requirements, manage licensing and qualification reviews, and ensure continuous quality improvement throughout all service lines. Essential Duties and Responsibilities Compliance & Regulatory Oversight Ensure organizational compliance with all applicable regulations, licensing standards, waivers, and provider requirements. Monitor regulatory updates and implement organizational changes as needed. Conduct internal compliance reviews and audits. Develop corrective action plans and monitor implementation. Serve as a resource to leadership regarding regulatory and compliance matters. Prepare for and participate in licensing inspections, audits, and regulatory reviews. Certified Investigator Responsibilities Serve as the organization's Certified Investigator. Conduct investigations involving incidents, allegations, abuse, neglect, exploitation, rights violations, and other reportable events. Ensure investigations are completed accurately, objectively, and within required timelines. Submit reports and documentation to regulatory agencies as required. Track investigation trends and recommend risk reduction strategies. Quality Assurance & Improvement (QA&I) Lead the organization's Quality Assurance and Improvement Program. Conduct regular QA&I reviews across all programs. Analyze performance metrics, incident trends, satisfaction data, and quality indicators. Develop quality improvement initiatives and monitor outcomes. Prepare quality management reports for executive leadership. Performance-Based Contracting Oversee organizational compliance with Performance-Based Contracting requirements. Monitor performance indicators and contract deliverables. Ensure data collection, reporting, and documentation meet contractual obligations. Collaborate with program leadership to achieve performance benchmarks and outcomes. Licensing & Qualification Reviews Manage licensing applications, renewals, and compliance requirements. Conduct staff qualification reviews to ensure compliance with position requirements and regulations. Maintain systems for tracking certifications, training requirements, and employee qualifications. Ensure personnel records meet regulatory and organizational standards. Policy & Procedure Management Develop, review, and maintain organizational policies and procedures. Ensure policies remain current with regulatory requirements and best practices. Coordinate policy implementation and staff communication. Lead periodic policy review processes. Leadership & Program Support Partner with the CEO to develop strategic compliance and quality initiatives. Provide leadership and guidance to program managers and supervisory staff. Assist with organizational risk management activities. Participate in leadership meetings and strategic planning efforts. Support organizational growth initiatives, licensing expansions, and program development. QualificationsEducation Bachelor's Degree required in Human Services, Social Work, Healthcare Administration, Business Administration, Psychology, Nursing, or related field. Master's Degree. Experience Minimum of 5 years of leadership or management experience in human services, intellectual disabilities/autism services, behavioral health, healthcare, or related field. Experience with Pennsylvania ODP regulations preferred. Experience managing compliance programs, investigations, licensing, and quality management activities required. Experience conducting audits, quality reviews, and corrective action planning preferred. Certifications Certified Investigator Certification required or ability to obtain within designated timeframe. Additional quality management, compliance, or healthcare certifications preferred. Knowledge, Skills, and Abilities Strong knowledge of state and federal regulatory requirements. Knowledge of
ODP 6400, 6100, ISP
manual regulations, incident management, licensing, and quality management. Excellent investigative and analytical skills. Strong written communication and report-writing abilities. Ability to interpret regulations and apply them operationally. Strong organizational and project management skills. Ability to maintain confidentiality and exercise sound professional judgment. Proficiency with Microsoft Office and electronic documentation systems. Leadership Expectations This position serves as a strategic collaboration with the CEO and is expected to promote a culture of compliance, accountability, quality, and continuous improvement throughout the organization while ensuring LNL remains a provider of excellence.
