Quality Assurance/Quality Improvement Director - Mental Health

Description

The Quality Assurance/Quality Improvement Director reports to the CEO and the Corporate Compliance Committee. This position safeguards agency standards by ensuring compliance with established external and internal control procedures and regulations. Working together with the Corporate Compliance Committee, this role is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance program and to propose policy and procedural changes for consideration.

Quality Assurance/Quality Improvement Job Function:

Will oversee the activity of the quality assurance department and staff, developing, implementing, and maintaining a system of

quality and reliability testing for the organization’s products and /or development processes.

Responsibilities and Duties

· Monitor risk management activities

· Review the implementation and efficiency of agency's quality systems

· Drive quality control program to meet the agency's high-quality standards by auditing systems for quality documentation and client health records for all services to ensure that Medicaid and/or any other auditing agency such as the LME standards are met.

· Analyze and communicate all areas for quality data improvement to department managers/supervisors

· Develop, recommend, and monitor corrective and preventative actions

· Lead and facilitate continuous quality improvement efforts using analytical methodologies

· Collect and compile statistical quality data

· Coordinate and support on-site audits conducted by external providers

· Evaluate audit findings, interpret and implement quality assurance and improvement standards and procedures

· Identify training needs and organize training interventions to meet quality standards

· Attend and participate in quarterly QA/QI committee meetings

· Perform any other job-related duties as specified by supervisor

· Maintains strict confidentiality according to all Federal and State guidelines and requirements.

· Exemplifies personal and professional conduct.

· Upholds the Professional Code of Ethics.

· Maintains a cooperative relationship with employees, medical staff and others.

· Adheres to and supports facility policies, programs and activities.

· Demonstrates tact, courtesy, and a positive approach to communication and interaction with other employees, visitors, physicians, etc.

· Responsible for maintaining a safe, clean and drug free environment.

· Willingness to work beyond what is required periodically and travel for continuing education hours

Communication:

· Work with a team approach with other employees to ensure agency compliance.

· Work closely with department heads to integrate QA/QI into daily operations.

· Present findings and recommendations to senior leadership.

· Serve as a liaison with external regulatory and accreditation bodies.

· Report critical concerns and problems to Supervisor in a timely manner and actively seek Supervisor’s input and assistance to

resolving the concern.

· Follow chain of command when encountering problems or other areas of need and correct problems requested.

· Solicit and cooperate with the assistance of all support staff.

· Actively participate in an appropriate manner with the decision-making process as “pro-active” team member and cooperate

with team’s decision, whether programmatic or clinical.

· Provide coverage on-site or as assigned by the needs of the agency.

· Attend staff meetings, planned in-service training, on-going training and any other regular or assigned meetings.

· Responsible for any equipment assigned to perform duties.

Facilitate flow of information.

Requirements

Education: A Bachelor’s degree required; Master’s degree preferred.

Experience: A minimum of five (5) years’ experience in a healthcare organization, to include demonstrated leadership. Familiarity

with operational, financial, quality assurance, and human resource procedures and regulations is a must.

Qualifications:

• Successfully pass criminal records check, finger printing, and background check as a prerequisite for employment consideration.
• Must successfully complete all core required trainings and updates as needed.
• Must have reliable transportation, maintain required level of vehicle insurance and valid driver’s license. Must be available to
• travel.
• Knowledgeable about national accreditation, State, Federal, and Agency Compliance, Documentation Skills, Attention to Detail, Reporting Research Results, Thoroughness, Excellent Written and Verbal Communication, Presentation Skills, Professionalism, Objectivity.