Quality Assurance Director

3 days ago

Great Falls, MT, United States Center for Mental Health Full time
Full-Time/Exempt (Locations: Great Falls, Helena, Havre, Conrad)

Job Duties:
  • Clinical Quality
    • Interprets and implements quality assurance standards.
    • Reviews clinical policies and procedures for quality and compliance.
    • Provides monitoring for preventive and corrective actions.
    • Identifies training needs and organize training interventions to meet quality standards.
    • Monitors risk management activities, reporting significant findings to Executive.
    • Reviewing client grievances and complaints and provides recommendations for clinical quality.
    • Development and implementation of an annual, formal, and comprehensive data-driven Continuous Quality Improvement (CQI) plan for CCBHC requirement.
    • Supports and monitors outcome measures model.
    • Reviews client and medication incident reports; recommends procedural and/or clinical policy changes.
    • Prepares Monthly Incident Review Tracking Form, Reviews in Monthly Clinical Director's meeting.
    • Facilitates proper documentation and reporting of significant incidents such as critical incidents and potential client abuse and/or neglect.
    • Collaborates on manuals to include Clinical, Program, Quality Assurance and Leadership.
  • Audit/Surveys
    • Conducts and/or oversees agency and program clinical audits such as those from DPHHS, SURS, Division of Quality Assurance, VA, WICHE, etc.
    • Coordinates and supports on-site audits conducted by external agencies.
    • Prepares reports for Leadership to communicate outcomes of quality activities and develops formal written response for audits.
    • Evaluates audit findings, developing a corrective action plan with the COO and Directors, monitoring progress and completion.
    • Collaborates with Leadership regarding audit processes and results.
    • Initiates, analyzes, and prepares report regarding client surveys.
    • Completes Annual Quality Assurance Report, quarterly and annual reports.
  • ARMS/Regulatory Requirements
    • Assures agency compliance with the ARMS in all clinical programs to include documentation that supports appropriate billing.
    • Assures ongoing compliance with quality and industry regulatory requirements.
    • Monitor the Administrative Rules of Montana. May train leadership and/or employees accordingly.
    • Creates policies and procedures that meet state and federal legal requirements.
  • Data Management
    • Devises sampling procedures and directions for recording and reporting quality data.
    • Collects and compiles statistical quality data.
    • Responsible for document management systems.
    • Completes necessary reports and assessments in a timely manner in accordance with agency policy.
  • Confidentiality Regulations:
    • Designated as the agency's HIPAA Privacy and Security Officer.
    • Conduct monitoring and investigates potential HIPAA breach violations.
    • Reporting for HIPAA violations to DPHHS.
    • Report issues pertaining to HIPAA to Leadership.
    • Supports proper documentation and processing of all HIPPA reports.
    • Completes necessary actions for correction of HIPAA concerns.
    • Submit reports of each HIPAA breach occurring within the agency to the Department of Public Health and Human Services within the first 60 days of the calendar year.
    • Reviews and approves records requests, may prepare clinical service summary letters as requested.
  • Training/Education
    • Provides consultation and education services to outside agencies and the public as assigned.
    • May represent the agency in giving comments to the ARMs hearings.
    • Provides new hire orientation training on overall agency guidelines, and HIPAA/ethics.
    • Conducts HIPAA training upon request with ongoing awareness of HIPAA policies and procedures.
    • Supports leadership in identifying culturally appropriate, trauma informed evidence-based practices for programs with additional guidance to implementation of those training models and monitoring for fidelity to the model.
  • CCBHC Evaluator
    • Collect and report on performance measures and Infrastructure, Prevention, and Promotion data.
    • Collect data on the clinic-level quality measures required under the CCBHC Certification Criteria and report on these data in the annual progress performance report.
    • Participate in all aspects of the National Evaluation of the program.
    • Facilitate measurement of progress towards the stated goals and objectives of CCBHC grant(s).
    • On-going collaboration with the CCBHC Grant Project Director and the National Evaluation Team.
    • Development of data collection workflows and facilitation of data collection protocols.
    • Data quality and data monitoring activities.
    • Data analysis and interpretation.
    • Implications for data-driven continuous quality improvement.
  • Additional Duties
    • Will attend Clinical Directors/Incident Review Committee and all CCBHC required meetings, trainings, and webinars.
    • Has authority to initiate and complete any step in the Performance Improvement Plan (PIP) process. Will collaboratively work with the levels of leadership involved.
    • May attend Senior Leadership, Supervisors, or other meetings as appropriate and assigned.
    • May perform emergency services both during and after normal work hours.
    • Must have valid MT driver's license, personal vehicle, and valid vehicle insurance will be traveling.
    • Required to complete CEUs as designated by clinical license, HIPAA/Security Officer requirements and CCBHC data management/population health management needs.
    • Performs other duties as assigned by Leadership.
Minimum Qualifications:
  • Graduation from a college or university with a Master's degree in social work or professional counseling.
  • Montana licensure is required for this level, LCSW or LCPC.
  • Minimum of three years' experience in clinical work is required.
  • Previous Supervisory experience is required.
  • HIPAA experience and HIPAA certifications preferred.
  • Required are knowledge of concepts, theories, principles, practices and methods of behavioral health programming and the ability to apply this knowledge to find unique and unprecedented solutions to client's clinical problems. Also required is knowledge of therapies, assessment, and the provision of consultation and education. Must have good organizational and leadership experience.
  • Thorough knowledge of the field of behavioral health and of the principles of delivery of behavioral health services; thorough knowledge of community resources useful in the treatment and prevention of emotional maladjustment.
  • Thorough knowledge of theory and practice in the field of specialization at a level appropriate for the training and experience required, thorough knowledge of the principles of community organization.
  • Thorough knowledge of principles and methods of supervision and in-service training, and the ability to supervise others. Thorough knowledge of the scope and activities of public and private health and welfare agencies.
  • Ability to give in-service training; to secure professional, clinical, or social work data and to record such data systematically; to interpret and evaluate the data and develop recommendations; and to write clear and accurate reports.
  • Travel is required to all offices.


Salary: $77,272.00 + DOE

All Positions at Many Rivers Whole Health must pass Background Checks and Motor Vehicle Record Check.

About Us:

Since 1976, we have been dedicated to 13 counties in Montana and seek to serve a variety of both individuals and groups in all settings. We define resilience as the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress - such as family and relationship problems, serious health problems, or workplace, school place and financial stressors - alongside those of chronic, severe disabling behavioral health conditions. with an integrated team of specialists and a personal approach to wellness. Today, we are focused on becoming Montana's healthcare provider of choice.

We are committed to recruiting qualified employees, continually striving for advancement, and above all, working as a team to meet the health needs of clients living in our 14 counties. Our vision is to be the healthcare provider of choice for clients and employer of choice for employees and providers. We will achieve this vision by committing to a culture of integrity, safety, evidence based exceptional care, compassionate customer service, and great work environment.

Our Mission: Many Rivers Whole Health partners with people and communities to serve the whole person - body, mind, and spirit - by providing expertise in wellness, mental health, and substance use disorders, addressing prevention and treatment with a recovery-based approach.

Vision: To be a community based, highly respected organization known for excellence in mental health and addiction recovery services, offering compassionate, client-focused, professional support.

Our Values: Ambassador of Many Rivers, Own it, Individuals Matter, Create Joy, Embrace Change, Show Up. Step In.

About Great Falls: Great Falls lies about halfway between Yellowstone and Glacier National Parks. With close access to world class fishing and floating, not only on the Missouri River, but also several other lakes and rivers. Great Falls is an active community within 1 hour of two local ski resorts. We encourage a fun, collaborative work environment as well as a good work/home life balance. If you are interested in being a part of a dynamic, impactful team, in a family friendly community, Great Falls and the Center for Mental Health is an excellent choice for you. We would love to hear from you and discuss this opportunity.

EQUAL OPPORTUNITY EMPLOYER:

Many Rivers Whole Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability). We encourage all qualified individuals to apply for employment. We do not discriminate against any applicant or employee based on protected veteran status, race, color, gender, sexual orientation, religion, national origin, age, disability, or any other basis protected by applicable law.

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