CCBHC Quality Assurance and Compliance Evaluator

CCBHC Evaluator

Job Purpose : The Quality Assurance and Compliance Evaluator oversees efforts to ensure compliance and quality related to company certifications, accreditations, and license requirements, including but not limited to the Certified Community Behavioral Health Clinic (CCBHC) program areas and company adherence to CARF standards. Primary responsibilities include assessing the effectiveness and efficiency of program operations, evaluating adherence to regulatory standards, and providing detailed reports on findings to inform continuous quality improvement activities. The evaluator works closely with program leadership, program staff, regulatory bodies, and other stakeholders to identify areas for enhancement and implementation of best practices. The role demands a keen eye for detail, strong analytical skills, and the ability to communicate complex information clearly and effectively.

Job Functions

1. Acts as the primary point of contact for evaluation concerns, and works with Director of Quality to facilitate any prescribed corrective action processes, whether internal or external.

2. Acquires and maintains knowledge of the requirements of grants / contracts that are awarded and ensures that the programs are meeting requirements.

3. Based on research and sound practice, makes recommendations for program structure and design, with the goal of designing programs embedded evaluation capacity. Assists in strategic planning sessions.

4. Performs / assists all activities outlined in various contracts associated with the evaluation of required activities. Ensures programs maintain the integrity of the services outlined in grants, AOP’s, contracts and other funding documents.

5. Assists programs in achieving model program status (NREP, Florida Level 2, through program evaluation efforts.

6. Assists in ongoing CARF accreditation compliance, quality and readiness activities including survey preparations and Quality Improvement Planning.

7. Supports the Quality Improvement activities of the company-wide, Board-approved Quality Management Improvement Plan attending quarterly meetings assisting in the analysis of data and related quality initiatives.

8. Periodically conducts reviews of all CCBHC, CARF and FQHC related programming to guarantee compliance and fidelity to the CCBHC model, CARF accreditation standards and Health Center requirements. In doing so, develops, implements, and oversees ongoing organization wide evaluation processes for evaluating the success of the organization in meeting the (9) core CCBHC service areas and all CARF standards; and collects, reviews, and analyzes data from this evaluation procedure to compile into quarterly and annual reports (more frequently as needed) to demonstrate organizational areas of strength and need, along with plans for enhancement of services. Reports should include specific data metrics to demonstrate progress towards goals (. utility / productivity), objective timelines for enhancement / improvement plans, data related to consumer experience with services, service fidelity to evidence based models / CARF / statutory regulations, and employee training / education and experience; reports should highlight overall trends identified through the analysis of all data combined.

9. Facilitates and oversees data collection to support CCBHC, CARF, FQHC and other assigned areas. This includes primary oversight of the NOMS as it relates to training, collection, reporting, evaluation, and analysis of data. In doing so, develops, implements, and maintains an organization wide training plan on the NOMS and collects and compiles NOMS data from the electronic health record, client, and appropriate collateral sources and enter it into the SAMHSA Performance Accountability and Reporting System (SPARS), as required by the CCBHC grant. Utilizes data as part of the overall evaluation plan, as outlined in section (8) above.

10. Designs and facilitates focus groups with consumers, team members, and community partners to assist in the evaluation of the organization’s success in meeting service delivery goals under the CCBHC model; analyzes and integrates resulting data into the overall evaluation, as outlined in section (8) above.

11. Regularly reviews data gathered about clients, services, and employees. Examine data for important trends and summarizes to allow for review by senior management.

12. Collaborates with leadership, such as from information technology, procurement, finance, human resources, medical, and clinical, to develop, implement, and maintain user-friendly, efficient, and effective systems for training, service delivery, and evaluation of services related to the CCBHC, CARF and other regulatory bodies.

13. Maintains a repository of information on program evaluation activities happening throughout Aspire, including respective Evidence Based Practices, CCBHC, FQHC, CARF and other areas as assigned.

14. Participates in required meetings related to the CCBHC, CARF, FQHC and other regulatory bodies at the program, leadership, and governmental levels, as requested.

15. Adapts functions to the emerging program evaluation needs of Aspire.

16. Assists in the writing of proposals and grants to secure current or additional funding specifically focusing on the evaluation and outcome sections of funding proposals.

17. Maintains high standards of ethical and professional conduct and adheres to Agency policies and procedures.

18. Performs other related duties as assigned by management.

Position qualifications : Ability to receive and maintain a(n)

• Requires a minimum BA in health care administration, business, data analytics, or like college university program. MA / MS preferred. Requires at least 3 years of increasing professional responsibility for design, implementation, and supervision of program evaluation activities.
• Experience in conducting, designing, implementing, analyzing program evaluation and publishing the results is highly preferred.
• Experience in writing grants and other funding proposals highly preferred.
• Level II Background clearance
• Acceptable Motor Vehicle Registration driver’s license record in accordance with the underwriting guidelines set by Aspire’s insurance company as described in the AHP Corporate Transportation Policy 3.9.1