Standards Compliance Officer in Rusk, TX

Description

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage.

Functional Title: Standards Compliance Officer 
Job Title: Manager II 
Agency: Health & Human Services Comm 
Department: Quality Mgmt 
Posting Number: 12991 
Closing Date: 03/05/2026 
Posting Audience: Internal and External 
Occupational Category: Management 
Salary Group: TEXAS-B-23 
Salary Range: $5,098.66 - $8,304.83 
Pay Frequency: Monthly
Shift: Day 
Additional Shift:  
Telework: Not Eligible for Telework 
Travel: Up to 10% 
Regular/Temporary: Regular 
Full Time/Part Time: Full time 
FLSA Exempt/Non-Exempt: Exempt 
Facility Location: Rusk State Hospital 
Job Location City: RUSK 
Job Location Address: 805 N DICKINSON DR 
Other Locations:  
MOS Codes: 0203,0207,0302,0520,0602,0802,1802,5502,6302,6502,7202,7208,7210,7220,111X,112X,113X,114X,16GX,41AX 
611X,612X,631X,632X,641X,648X,86M0,86P0,8U000,9G100,SEI15 
 
 

Brief Job Description:

Would you thrive in an environment where you learn and grow personally and professionally all while helping make a positive impact on people's lives? Do you appreciate being around others like yourself who are dependable, trustworthy, hard workers who believe in the value of teamwork? HSCS is dedicated to building an atmosphere where employees feel valued and supported while providing specialized care for Texans in need. HSCS is comprised of eleven psychiatric hospitals, two youth residential treatment facilities, and thirteen state supported living centers. Psychiatric hospitals are a hub of excellence for forensic mental health and complex psychiatric care, with all facilities accredited by The Joint Commission. They provide state-of-the-art treatment that is recovery-oriented and science-based. If providing hope and healing through compassionate, innovative, and individualized care interests you, we welcome your application for the position below.

The Manager II (Standards Compliance Officer) performs moderately complex (journey-level) managerial work administering the daily operations and activities of an agency's business function, division, or department. Works under general supervision, with limited latitude for the use of initiative and independent judgment. Requires specialized knowledge in planning, development, implementation, and monitoring of quality assurance systems. Ensures the facility conforms to the conditions of participation for the facility as a Centers for Medicaid and Medicare Services (CMS) provider serving persons with mental health diagnoses, the Joint Commission (TJC) standards, and all other relevant state and federal laws, rules, and regulations.  Interprets regulations/standards, develops, and disseminates policy, performs advanced consultative services to program staff, and coordinates a comprehensive system of implementing and reporting on quality enhancement efforts. Oversees assigned indicators including monitoring, data collection, analysis, presentation, and hospital wide reporting of the same through the hospitals committee structure. Serves as a member, facilitator, or consultant on assigned hospital standing committees including Pharmacy and Therapeutics, Environment of Care, Performance Improvement, Risk Management, and Medical Executive. Facilitates special projects as assigned by hospital leadership. Works closely with hospital leadership and committees in evaluating and improving the clinical safety program at the hospital. Coordinates and oversees activities of and participates in the development and implementation of the hospital Clinical Safety Program including proactive assessments of patient safety concerns and determination of standards compliance, development and oversight of the collection, analysis, and reporting of data related to clinical safety, and participates in various hospital committees assigned. Serves as the primary consultant and active participant on Root Cause Analysis, Management Initiated Reviews, and Proactive Risk Assessments. Monitors plan of correction for Management Initiated Reviews and Root Cause Analysis and maintain tracking mechanisms to track trends and to ensure all are completed in a timely manner. Makes recommendations related to trends in data. Participates in the development of staff education related to patient safety concerns. Supports the hospital's overall Joint Commission and CMS survey and continuous readiness activities. Must understand that the duties, location of work and shift pattern are subject to change as determined by administration in order to meet department and hospital needs. Must understand that the duties may include exposure to blood or other potential infectious materials. Employee actively participates and/or serves in a supporting role to meet the agency's obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Supports and mission and vision of the hospital. 

Performs other duties as assigned. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency's obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

Essential Job Functions (EJFs):

Attends work on a regular basis and may be asked to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned. 

Oversees assigned indicators including monitoring, data collection, analysis, presentation, and hospital wide reporting of the same through the hospitals committee structure.

Serves as a member, facilitator, or consultant on assigned hospital standing committees including Pharmacy and Therapeutics, Environment of Care, Performance Improvement, Risk Management, and Medical Executive.

Facilitates special projects as assigned by hospital leadership.

Works closely with hospital leadership and committees in evaluating and improving the clinical safety program at the hospital. Coordinates and oversees activities of and participates in the development and implementation of the hospital Clinical Safety Program including proactive assessments of patient safety concerns and determination of standards compliance, development and oversight of the collection, analysis, and reporting of data related to clinical safety, and participates in various hospital committees, as assigned.

Serves as the primary consultant and active participant on Root Cause Analysis, Management Initiated Reviews, and Proactive Risk Assessments. Monitors plan of correction for Management Initiated Reviews and Root Cause Analysis and maintain tracking mechanisms to track trends and to ensure all are completed in a timely manner. Makes recommendations related to trends in data.

Participates in the development of staff education related to patient safety concerns.

Supports the hospital's overall Joint Commission and CMS survey and continuous readiness activities.

Ensures the facility conforms to the conditions of participation for the facility as a Centers for Medicaid and Medicare Services (CMS) provider serving persons with mental health diagnoses, the Joint Commission (TJC) standards, and all other relevant state and federal laws, rules, and regulations.  Interprets regulations/standards, develops, and disseminates policy, performs advanced consultative services to program staff, and coordinates a comprehensive system of implementing and reporting on quality enhancement efforts.

Performs other duties as assigned. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency's obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

Knowledge, Skills and Abilities (KSAs):

Knowledgeable of issues related to patient safety

Skills in completing Root Cause Analysis, Management Initiated Reviews, and Proactive Risk Assessments.

Skills in using performance improvement and quality monitoring processes.

Ability to complete clinical audits and reports and maintain records.

Ability to devise solutions to problems.

Ability to communicate effectively.

Skill using Microsoft Outlook, Word, and Excel.

Knowledge of HIPAA, CMS, Joint Commission, Texas Administrative Code, and survey readiness techniques.

Ability to interpret standards and apply appropriately.

Knowledge of electronic medical records.

Ability to gather, assemble, correlate, and analyze facts to prepare reports.

Ability to write policy, identify need for policy update or new policy.

Registrations, Licensure Requirements or Certifications:

Valid government identification.

Initial Screening Criteria:

Experience reviewing clinical documentation.

Three years of clinical work experience in nursing, social work, psychology, or related field preferred.

Additional Information:

Applicants must pass a fingerprint criminal background check, pre-employment drug screen, and registry checks including the Client Abuse/Neglect Reporting System (CANRS), Nurse Aid, Medication Aide and Employee Misconduct, List of Excluded Individuals/Entities (LEIE). Males between the ages of 18-25 must be registered with the Selective Service.

All applicants must be at least 18 years of age to be considered for employment at a state-operated facility. Waco Center for Youth applicants must be 21 years of age.

Flexibility in work hours may be required for this position. The position may be required to work overtime and/or extended hours.

Compliance with HHSC immunization policy and state hospital operating procedures related to immunizations is required. According to the Centers for Disease Control and Prevention, healthcare workers are at significant risk for acquiring or transmitting hepatitis B, measles, mumps, rubella, varicella (chicken pox), tetanus, diphtheria, pertussis (whooping cough), and influenza. All these diseases are vaccine preventable. Vaccines may be provided. As a result, state hospital policy requires employees be vaccinated according to their level of contact with individuals. In the event you choose to not be immunized for the influenza virus, you may be required to wear a mask and take other protective measures.

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Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor's Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.