Quality Improvement & Compliance Manager

This is a highly responsible position requiring a high degree of independent judgment, initiative, and data management and interpretation skills. Responsibilities include coordination, planning and directing of all quality improvement and performance improvement-related policies, programs, services and activities; development, implementation, administration, coordination and integration of systematic service evaluation/outcomes and research programs and projects. Responsibilities also include control, coordination, implementation and monitoring of licensure, certification and accreditation.

MINIMUM QUALIFICATIONS:

Education, Training, and/or Experience:

  • Bachelor’s degree in business administration, social work administration, or in a related human service field with a minimum of three (3) years relevant professional and administrative experience particularly in the areas of quality improvement and/or program evaluation.
  • Must have experience with licensing, certification and/or accreditation processes preferably with CARF, COA and/or JACHO;
  • Comprehensive and demonstrated knowledge of computer operations as related to outcomes and quality improvement activities
  • Proven proficiency with Access, Excel, PowerPoint, Word and SPSS or SAS and other agency software

Certifications, Licenses, Registrations:

  • Must have and maintain a valid Ohio Driver’s License, personal vehicle, appropriate driving record, and appropriate insurance coverage at all times (as required by agency policy and/or insurance carriers).
  • Successful completion of all required pre-hire tests and proof of current TB test upon hire

ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES:

Other duties may be assigned. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made for qualified individuals to perform the essential duties.

1. Interprets, develops and implements system-wide quality/performance improvement standards, policies, procedures and activities to ensure quality care to clients/consumers.

2. Reviews quality improvement standards, develops and updates existing policies and procedures, interviews agency personnel and consumers to evaluate effectiveness of services and programs.

3. Conducts clinical, peer and utilization reviews and oversees/monitors the “Measurement, Review, and Reporting” process as specified for (a) Medical Records, (b) licensure, certification, accreditation requirements (OhioMHAS, ODJFS, ADAMHSCC, COA), and/or (c) other specific topics for review such as problem procedures, high volume cases, high risk cases and/or other factors; discusses findings and recommendations with supervisor, administrative team and QI Committee.

(a) Notifies staff of any required corrective actions including those for ICR documentation;

(b) Maintains a log of the notices sent and responses received;

(c) Oversees the re-audits of the corrective actions taken by staff.

4. Compiles statistical data, summarizes findings and writes and submits quality improvement reports including:

(a) QI monthly/quarterly/annual Reports including ADAMHSCC and OhioMHAS, the bi-annual PI (Performance Improvement) reports and other reports as assigned,

(b) Ensures the inclusion of QI data for all agency(ies) affiliated programs.

5. Manages/oversees the collection, computer entry, and analysis of the data from the Clinical Record reviews, Peer Reviews, Utilization Reviews, Outcomes Monitoring and other applicable PI/QI functions; utilizes data to monitor other required aspects of care as specified in the QI/PI Plan or to conduct other assigned reviews.

6. Serves as QI/PI liaison with licensing/funding/accrediting bodies.

7. Assists with preparation, implementation, and coordination of efforts toward the development of QI and PI philosophy within the organizational culture (e.g., team building, educational presentations).

8. Serves as an information resource for supervisors and staff with regard to quality improvement standards and documentation requirements, and conducts in-service training sessions, including orientation and the philosophy and process of quality improvement at the agency(ies), as well as individual/group training as needed/assigned.

9. Responsible for identification of problems and areas for improvement with clinical documentation, development of corrective action plans, and monitoring of changes.

10. Serves as the agency’s compliance officer related to certification/accreditation standards of an assigned agency

(a) Coordinates audits and ensures agency compliance;

(b) Assists auditors during audit process;

(c) Coordinates Corrective Action Plans and submits written response, as necessary.

11. Ensures timely compliance with all agency policies and applicable standards required by funding, certification and/or accrediting bodies/organizations for facilities and services provided within assigned agency programs.

12. Oversees the evaluation/outcome, research and follow-up programs, system-wide.

(a) Ensures design of research projects and the recommendation and preparation of proposals to funding agencies;

(b) Assists with developing service evaluation plan, appropriate measurement instruments and the obtaining, assembling, analyzing and interpretation of appropriate data.

13. Coordinates and monitors the implementation of all outcomes, evaluation and research tools used at the agency. Synthesizes data and reports findings as needed.

Knowledge, Skills & Abilities

1. Knowledge of the quality/performance improvement requirements as outlined by OhioMHAS, ODJFS, ADAMHSCC and other funding/accrediting sources, as assigned

2. Ability to maintain and increase knowledge of professional trends in community mental health services; mental health issues, the clinical process and the requirements of clinical documentation

3. Excellent oral, written and presentation communication skills; ability to effectively respond to complaints

4. Demonstrated ability with complex record-keeping functions, and communication/retrieval of information.

5. Ability to read, analyze and interpret periodicals, professional journals, technical procedures and/or government regulations, financial and/or legal reports.

6. Knowledge of efficient planning/organizing and scheduling of work priorities; ability to setup, maintain and/or retrieve program files in compliance with sound business practices, appropriate and required confidentiality, funding and accreditation bodies, etc.

7. Demonstrated ability to direct staff engaged in various quality improvement and research and evaluation programs.

8. Supports the organization’s overall mission and values including initiative, teamwork, and flexibility. Supports agency philosophy, values, and goals and is conscientious about all organizational values.

9. Ability to become thoroughly familiar and comply with the applicable rules, regulations, standards, functions, procedures, organization and policies governing the operations of the agency; ability to analyze problems and develop plan of action/correction.

10. Demonstrates leadership by: working collaboratively with others to improve the organization’s efficiency and effectiveness; promoting and modeling a healthy work environment characterized by fairness and respect; maintaining direct and open communication, mutual support and encouragement throughout the organization, and promoting professional growth of self and others.

11. Ability to maintain appropriate and required confidentiality ensuring the integrity of sensitive information (written and/or verbal).

12. Demonstrates sound judgment and the ability to determine key needs, diagnose and address problems, assertively follow-up on deficiencies and monitor progress of important initiatives and activities.
13. Demonstrated expertise in applicable computer software systems and keyboarding

Job Type: Full-time

Work Location:

  • Multiple locations

Benefits:

  • Health insurance
  • Dental insurance
  • Vision insurance
  • Retirement plan
  • Paid time off

Schedule:

  • Monday to Friday