Quality Improvement Director/Compliance Officer

 Job Title: Quality Improvement Director/Compliance Officer

Reports To: VP of Operations

FLSA: Exempt

Department: Clinic

Description

The Quality Improvement Director/Compliance Officer primary task will be to provide Medi-cal oversight to all clinical staff of Psynergy Program Inc.; consult with several community groups and agencies on mental health services and awareness; and set up service delivery systems.  This position will also have oversight and responsibilities ensuring the Compliance Plan is current and up to date.

The Quality Improvement Unit of the Psynergy Program Inc reports to VP, Clinical and Residential Operations.  This person will travel/drive throughout the Psynergy Programs to perform the duties of the position when required; additionally, may attend meetings, trainings and conferences at various locations throughout the state. 

This Quality Improvement Director will perform quality management through auditing, data collection, analysis, and evaluation of programs in Psynergy Program Inc; Provide and develop training, technical assistance, and other support services for managers, staff, and clients; assist in quality oversight, addressing risk management of clinical issues; act as liaison to staff and providers; ability to lead quality improvement projects; use technical aptitude to learn new computer programs and train others; use automated systems such as Excel and  EMR (electronic medical record) to collect data and report out to Executive Management.

Responsibilities and duties:

The ideal candidate for this position will possess the following:  

•    Establish and maintain program procedures which are consistent with Federal, State and local laws governing mental health services.

•    Monitor and consult with County and State Agencies to ensure compliance with services requested by the County and help determine jointly beneficial solutions to problem areas.

•    Conducts clinical record documentation reviews prepares data; reviews clinical records for compliance with regulatory and quality of care standards; provides feedback to providers; prepares reports.

•    Develops, provides training, including online training, videoconferences, and technical assistance for managers and line staff on clinical record documentation rules and procedures.

•    Assist County MHP’s with site certification reviews of Psynergy Program Inc. clinics.

•    Evaluate and integrate changes in legislation into the program procedures.

•    Provide clinical consultation to various agencies.

•    Compile data and prepare program evaluations and other reports.

•    Supervises the Utilization Review Team, audits and writes reports of finding.

•    Develop and write the yearly Quality Improvement Work Plan

•    Develop program objectives and goals and establish priorities.

•    Write and assist in the implementation of Policy and Procedures

•    Monitor contract Outcome Measures

•    Participate in the grievance process as appropriate.

•    Prepares Plan of Corrections for the auditing counties

•    Ensure compliance with various reporting requirements.

•    Oversee and implement the Compliance Plan

•    Provides education and training in promoting ethical delivery of services.

•    Investigate and resolve systemic problems identified through audit, monitoring review or reporting process.

•    Perform related duties as assigned.

Typical Work Activities:

Typical work activities vary depending on the size and type of facility, but may include:

•    Experience conducting clinical document reviews for compliance; collecting and compiling data; preparing reports; and providing feedback to providers.

•    Experience developing and providing training and technical assistance for staff and providers.

•    Assist with all necessary information for County MHP’s when they are conducting site certification reviews.

•    Knowledge of mental health laws and regulations.

•    Proficient in using Excel, EMR, and online training development.

•    Knowledge of current best practices in the fields of addiction treatment and behavioral health regarding co-occurring substance use and mental illness.

•    Ability to communicate well in large public groups and oversee the work product of a large number of individuals implementing program-based quality improvement activities. 

•    Strong organizational skills, with an ability to work within multiple systems promoting change, while managing many levels of detail in implementation.

•    Ability to provide leadership and promote quality improvement process, as well as an ability to negotiate, solve complex problems, and resolve conflict.

•    Knowledge of best practices in providing services for a diverse client population and ensuring appropriate culturally competent practices.

•    Ability to supervise staff.

•    Must pass a background check.

Qualifications:

Licensure/Certification:  California license as one of the following: 1) Clinical Social Worker; 2) Marriage and Family Therapist; or 3) Clinical Psychologist. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Prepare written reports; set realistic treatment goals and facilitate their attainment; evaluate patients/clients degree of mental disability or emotional distress; and supervise and train interdisciplinary subordinates.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience:

Any combination of education and experience that would likely provide the required knowledge, skills and abilities is qualifying. A typical way to qualify is three years of experience as a Mental Health professional.

Knowledge and Skills:

Basic program management techniques and practices; individual, group and family psychodynamics; psychological diagnostic methods and terminology; current principles and practices of psychiatric casework; human and health services systems in the County including private agencies and other community resources; various methods used in individual and group therapies such as role playing, play, art and milieu; and methods and techniques used in mental health education.

Ability to engage and communicate effectively with others; Ability to follow directions and work within a program structure.

Language Ability:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of an organization.

Math Ability:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability:

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized and emergency situations.

Computer Skills:

To perform this job successfully, an individual should have knowledge of Microsoft Word; Microsoft Excel; inventory software; internet software; order processing systems; and database software.

Certificates and Licenses:

•    Valid Driver’s License - Must meet insurance underwriting requirements.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally exposed to toxic or caustic chemicals and outdoor weather conditions. The noise level in the work environment is usually moderate.

Special Requirements:

Must be able to meet and receive a criminal records clearance as required by Title XXII, licensing regulations. This includes FBI and DOJ clearance. A health screening, by or under the direction of a physician must have been performed not more than one year prior to employment or within seven (7) days after employment. Health screening must include TB clearance not more than one year prior to employment or within seven (7) days after employment. Must have a “valid” standard first aid card from an accredited institution. Must be physically able to assist clients and/or staff in the evacuation of program facility in emergency situations. Must be able to administer first aid in an emergency.

Physical Requirements of Position:

The following are required in day-to-day performance of the duties of this position: Walking, Sitting, Pinching and Finger Flexion, and Visual/Auditory Acuity are required constantly (over 2/3 of the workday); Lifting, Carrying, Pushing, Pulling, Bending, Stooping, Crouching, Kneeling and Twisting are required occasionally (under 1/3 of the workday). Balancing, Climbing and Crawling are generally not required.