Director of Quality Assurance

5 days ago

Texas City, Texas, United States Summit BHC Full time
About the Job

The Director of Quality and Performance Improvement is responsible for developing and implementing work plans, systems, processes, and policies to ensure compliance with all licensure, insurance, accreditation, and certification agencies, federal, and state regulations and laws, and improvement of client safety and quality of care.

Key Responsibilities
  • Monitor and direct the day-to-day operations of quality management and compliance processes within the organization to establish and maintain a culture of compliance and safety.
  • Continually assess the facility survey readiness and function as survey coordinator during any regulatory survey.
  • Coordinate regulatory activities, including licensure, certification, and accreditation, and serve as liaison to regulatory agencies.
  • Lead a team of highly engaged members through hiring, orienting, performance assessment, and management to meet department goals and ensure effective and efficient department operation.
  • Develop, review, and update internal clinical procedures, related outcomes measurement, client satisfaction, clinical/financial scorecards to ensure ongoing compliance with federal, state, and other third-party regulatory requirements and improvement of services.
  • Respond to alleged violations of rules, regulations, and policies, and coordinate resolution of ethics reports with appropriate staff/department.
  • Maintain proficiency in regulatory planning strategy and the submission of regulatory plans, and develop corrective action plans for the resolution of problematic issues or to address areas of compliance vulnerability.
  • Collect and provide data for compliance requests, dashboards, and scorecards, and prepare and submit accurate and comprehensive reports as required both internally and externally.
  • Oversee the coordination of internal and external governmental compliance/privacy investigations or reimbursement reviews at the facility to ensure investigations/reviews are conducted appropriately and that responses to external entities are consistent with facility standards and expectations.
  • Provide a broad vision in the strategic development and direction of the performance improvement program for the facility, and develop a facility-wide performance improvement plan and PI tools.
  • Determine if services meet pre-determined quality improvement expectations and outcomes, and develop written plans to improve and/or correct quality, safety, and appropriateness of client care.
  • Conduct routine evaluations of the effectiveness of services and ensure correction of any observed deficiencies identified through the quality improvement process.
  • Conduct timely and regular evaluation of serious incidents, complaints, grievances, and related investigations.
  • Provide research, analysis, and consultation on regulatory requirements, and maintain current and updated facility accreditation and regulatory standards manuals.
  • Ensure proper facility reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
Requirements
  • Bachelor's Degree in Nursing or Human Services field required; Master's Degree in Human Services preferred.
  • Three or more years' experience in Quality Management, PI role, facility licensure, survey, and credentialing process required; experience in a behavioral health setting preferred.
  • Experience with TJC and/or CARF accreditation and regulatory audits preferred.
  • Working knowledge of Regulatory Compliance.
  • Professional clinical license issued by the appropriate licensing body as required by the state.
  • CPR and de-escalation certification required (training available upon hire and offered by facility).
  • First aid may be required based on state or facility.

Great Oaks Recovery Center offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications.

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