What are the responsibilities and job description for the Quality Improvement Director position at LIGHTSHARE BEHAVIORAL WELLNESS & RECOVERY?
SUMMARY OF RESPONSIBILITIES:
This position provides leadership, guidance, and direction for the systematic monitoring and evaluation of clinical care across the organization. The QI Director manages agency wide quality improvement and compliance activities through compiling, analyzing, and interpreting data into actionable opportunities for improvement. The position requires the ability to review and understand contracts and includes tracking deadlines to assure compliance with contractual obligations. This position develops and monitors continuous quality improvement activities designed to assure compliance with accreditation and regulatory requirements.
MINIMUM QUALIFICATIONS:
Master’s degree in a health-related clinical area of study, Healthcare Administration, Public Health or other related field from an accredited College or University required.
At least 2 years’ experience in quality improvement systems and activities.
Experience managing and communicating data is preferred.
Excellent communication skills.
At least 2 years in behavioral healthcare.
ESSENTIAL DUTIES/RESPONSIBILITIES:
Responsible for ongoing CARF accreditation and other regulatory readiness and review of standards.
Completes required reports/plans for oversight activities and manages external auditing processes. Develops and submits corrective actions if required following auditing.
Leads the agency efforts in the areas of licensure, accreditation, performance outcomes and improvement, coordinates the tracking and analysis of those activities.
Help the department develop data-driven strategic decisions for developing QI projects guiding resources based on need.
Collaborates on an ongoing basis with operations clinical teams to improve outcome performance.
Assists with policy/procedure development and review based on changes in standards. Monitor practices necessary to meet those standards.
Prepares necessary reports required by contracts including but not limited to the agency’s performance measures and outcomes management.
Chairs Quality and Safety Committees.
Serves as the main point of contact 24/7 for internal incident reporting purposes. Assures external incident reporting is conducted according to regulatory requirements.
Investigates incident reports, individual complaints, care issues, and other issues as requested by the Maintains confidence of agency leadership and community by keeping information confidential, following established policy and procedure.
Maintains data integrity of these strategically important metrics with regular presentation and communication of the data collected.
Assists with Quality Improvement culture through the management of the Relias Learning Management System.
Completes all other duties and special projects as assigned.
CORE COMPETENCIES
Demonstrates Dependability:
Arrives to work on time according to agency policies
Uses leave time according to agency policies
Completes documentation/paperwork and projects within deadlines
Demonstrates Flexibility & Initiative:
Assumes additional responsibilities and a willingness to assist colleagues
Works different shifts when necessary
Recommends program changes and improvements
Demonstrates Teamwork:
Maintains an overall work attitude of cooperation and professionalism in all interactions with agency staff and community professionals
Attends and participates in required staff meetings and agency-wide committees
Receptive to direction and feedback from supervisor
Demonstrates Professionalism:
Conducts self in professional manner with colleagues, peers, and persons served
Recognizes the rights of clients; and will protect privacy of persons served at all times by following agency, State, and Federal mandated privacy procedures and regulations
Adheres to agency Code of Ethics at all times
Complies with all agency policies and procedures, laws and regulations under which the agency operates
