Director of Quality and Performance Improvement
3 weeks ago
We are seeking a highly skilled and experienced Director of Quality and Performance Improvement to join our team at Summit BHC. The successful candidate will be responsible for ensuring compliance with all licensure, insurance, accreditation, and certification agencies, as well as federal and state regulations and laws.
Key Responsibilities- Conduct and Implement Work Plans: Develop and implement work plans, systems, processes, and policies to ensure compliance with regulatory agencies and improve client safety and quality of care.
- Lead Quality Assessment and Performance Improvement: Direct and monitor the development and implementation of the overall facility quality assessment and performance improvement process to provide efficient and streamlined work-flow.
- Monitor and Direct Operations: Monitor and direct the day-to-day operations of quality management and compliance process within the organization to establish and maintain a culture of compliance and safety.
- Coordinate Regulatory Activities: Coordinate regulatory activities, including licensure, certification, and accreditation, and serve as liaison to regulatory agencies.
- Lead a Team: 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 and Implement Processes: 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.
- Respond to Alleged Violations: Respond to alleged violations of rules, regulations, and policies by evaluating and recommending investigations as appropriate.
- Maintain Proficiency: Maintain proficiency in regulatory planning strategy and the submission of regulatory plans.
- Provide Strategic Direction: Provide a broad vision in the strategic development and direction of the performance improvement program for the facility.
- Develop Performance Improvement Tools: Develop a facility-wide performance improvement plan and PI tools.
- Collect and Analyze Data: Develop processes for identification, collection, and analysis of performance measurement data.
- Evaluate Services: Determine if services meet pre-determined quality improvement expectations and outcomes.
- Conduct Evaluations: Conduct timely and regular evaluation of serious incidents, complaints, grievances, and related investigations.
- Provide Research and Analysis: Provide research, analysis, and consultation on regulatory requirements.
- Ensure Proper Reporting: Ensure proper facility reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required.
- Bachelor's Degree: Bachelor's Degree in Nursing or Human Services field required.
- Experience: Three or more years' experience in Quality Management, PI role, facility licensure, survey, and credentialing process required.
- Supervisory Experience: Two years' supervisory/management experience required, preferably in behavioral health.
- Preferred Qualifications: Experience with TJC and/or CARF accreditation and regulatory audits preferred.
- Certifications: CPR and de-escalation certification required (training available upon hire and offered by facility). First aid may be required based on state or facility.
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