Director-Quality Management - Acute

Director-Quality Management - Acute | Miramont Behavioral Health | Middleton, Wisconsin

About the Job:

PURPOSE STATEMENT:

The Director of Quality Management is responsible for conducting and implementing work plans, systems, processes and policies designed to ensure compliance with all licensure, insurance, accreditation and certification agencies, federal, and state regulations and laws. Directs and monitors the development and implementation of the overall Hospital quality assessment process to ensure safe and excellent client care delivery and to promote a high reliability organization.

Roles and Responsibilities:

ESSENTIAL FUNCTIONS:

• Monitors and directs the day-to-day operations of quality management and compliance process within the organization to establish and maintain a culture of compliance and safety.
• Continually assesses the hospital survey readiness. Functions as survey coordinator during any regulatory survey. In consultation with key managers, prepares responses to survey and addresses recommendations and areas needing improvement.
• Coordinates regulatory activities including licensure and accreditation (OHFLAC, BHHF, CMS, Joint Commission, Office of Civil Rights, etc.). Serves as liaison to the regulatory agencies related to activities within the organization.
• Leads a team of highly engaged members thru hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.
• Sets expectations, develops plans, and manages processes to measure, assess and improve the quality of clinical programs and/or regulatory/accreditation compliance by measurable results.
• Develops, reviews, and updates internal clinical procedures, related outcomes measurement, client satisfaction, clinical/financial scorecards to ensure ongoing compliance with federal, state and other third-party regulatory requirements.
• Responds to alleged violations of rules, regulations, and policies, by evaluating and recommending investigations as appropriate. Coordinates resolution of ethics reports with appropriate staff/department.
• Maintains proficiency in regulatory planning strategy and the submission of regulatory plans. Develops corrective action plans for the resolution of problematic issues or to address areas of compliance vulnerability.
• Collects and provides data for compliance requests, dashboards, and scorecards. Prepares and submits accurate and comprehensive reports as required both internally and externally.
• Oversees the coordination of internal and external governmental compliance/privacy investigations or reimbursement reviews at the facility to ensure investigations/reviews are conducted appropriately and that responses to external entities are consistent with facility standards and expectations.
• Provides research, analysis, and consultation on regulatory requirements. Maintains current and updated facility accreditation and regulatory standards manuals.
• Ensures proper facility reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required
  
  
  

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor’s Degree in Nursing or Human Services field required. Master’s Degree in Human Services preferred.
• Three or more years’ experience in Quality Management, hospital licensure, survey and credentialing process required. Experience in a behavioral health setting preferred.
• Experience with TJC accreditation and regulatory audits preferred.
• Knowledge and understanding of state / local regulations from applicable licensing agencies.
• Working knowledge of Regulatory Compliance.
  
  
  

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Professional clinical license issued by the appropriate licensing body as required by the state.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility.
  
  
  

SUPERVISORY REQUIREMENTS:

At least two years’ supervisory/management experience required, preferably in behavioral health.

Why Miramont Behavioral Health?Miramont Behavioral Health offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Miramont Behavioral Health is an EOE.

Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.