Job Title: Director of Quality Assurance and Compliance
DEPT: Administrative
Reports to: Chief Executive Officer
Salary Range: $62,353 – $72,314 annually
Position Summary: The Director of Quality Assurance and Compliance is responsible for leading and sustaining an organization-wide quality assurance, compliance, and risk management framework. The role is to ensure adherence to internal policies, program standards, and all applicable federal, state, local, and funder requirements, and promote continuous quality improvement.
Authority and Independence
The Director has authority to access records, systems, and personnel necessary to fulfill quality assurance and compliance responsibilities and may elevate significant compliance or risk concerns directly to the CEO and, as appropriate, the Board of Directors.
Minimum Qualifications:
Education
- Bachelor’s degree required in relevant field; Master’s degree preferred.
Experience
- Minimum of 3-5 years of progressively responsible experience in quality assurance, compliance, risk management, or non-profit oversight. Equivalent combinations of education and experience will be considered.
- Demonstrated ability to lead organization-wide QA and compliance initiatives.
- Demonstrated ability to manage incident reporting, investigation, documentation, corrective action, and follow-up.
Skills and Competencies
- Strong knowledge of HIPAA, NY Article 27-F, and other applicable regulatory requirements.
- Demonstrated ability to coordinate effectively with Program leadership and cross-functional partners.
- Proficiency in Microsoft Office applications (Word, Excel, Outlook, PowerPoint) and ability to use spreadsheets, databases, and reporting tools to tract compliance activities, analyze data, and prepare reports, with demonstrated experience applying these tools in a quality assurance, compliance or regulatory environment.
- Strong analytical, organizational, and communication skills.
- Sensitivity to and commitment for working with populations affected by HIV/AIDS, chronic illness, LGBTQ+ issues, and alignment with the mission, vision, and values of the agency.
- Ability to work independently while collaborating across departments.
Other Requirements
- Valid New York State driver’s license and reliable access to a vehicle with current insurance for work-related travel, training, outreach, and occasional client transport (personal vehicle ownership is not required but consistent access is necessary).
Primary Responsibilities
- Compliance Program and Risk Management
- Lead the organization’s internal quality assurance monitoring and compliance audits.
- Oversee the organization’s incident reporting and response process, including intake, investigation, documentation, follow-up, and escalation.
- Identify, document, and monitor organization-wide compliance risks.
- Maintain a centralized Compliance Risk Register tracking open items, severity, ownership, and resolution status.
- Coordinate with programs, Finance, Human Resources, Operations, Information Technology, and Facilities to ensure compliance-related dependencies are identified, assigned, resolved, documented, and monitored to closure.
Quality Improvement and Audits
- Lead internal QA monitoring and compliance audits, including program-level reviews.
- Participate in and support preparation for external audits, site visits, reviews and examinations.
- Coordinate and support preparation for programmatic, administrative, fiscal, and benefits-related audits.
- Track findings, management letter recommendations, and corrective actions across departments.
Committees, Emergency Preparedness & Safety
- Serve as Security Officer for electronic health records and maintain the confidentiality, integrity, and availability of records and protected health information (PHI/e-PHI), including data mapping and system updates.
- Monitor life safety, emergency preparedness, and facility-related compliance risks in collaboration with Program and Operations.
- Track and escalate unresolved safety or emergency compliance issues to senior leadership as appropriate.
- Organize and facilitate Compliance and Quality Improvement Committee meetings.
Data Systems & Confidentiality
- Ensure confidentiality, integrity, and availability of PHI/ePHI.
- Monitor privacy and confidentiality risks related to surveillance, access controls, and systems.
- Maintain awareness of and appropriate access to compliance-related systems and portals to ensure continuity.
Planning, Metrics & Reporting
- Maintain compliance calendar to ensure timely completion of recurring audits, certifications, and reports.
- Provide regular compliance status updates to Senior Leadership.
- Prepare and present annual quality assurance and compliance report to the Board of Directors.
- Ensure strict confidentiality in performance of job duties and communications in accordance with Article 27-F, HIPAA, and Agency policies.
- Perform other duties as assigned by Chief Executive Officer to advance organizational quality and compliance.
FLSA Status: Exempt
Location: Syracuse Office Hours per week: 35 Work Schedule: Full Time in Office
Disclaimer: This job description is intended to provide a general overview of the primary duties and responsibilities of the position. It is not an exhaustive list, and the employee may be required to perform other duties that fall within the scope of their responsibilities. These additional tasks will be assigned as needed and are consistent with the nature and level of the role.
