What are the responsibilities and job description for the Health Professional III- Occurrence Reporter CMHHIP position at State of Colorado Job Opportunities?
Department Information
Most State of Colorado employees are eligible for a great benefit package! Please see the Supplemental Information section below for details!
About Quality Management Department (CMHIP)
The Quality Management Department exists to guide and support CMHHIP’s efforts to meet or exceed customer expectations by maintaining excellence in patient safety and care, and to identify opportunities for improvement through data collection, analysis, interpretation and dissemination of data-based information that enables hospital leadership to utilize resources in an effective and efficient manner and to operate efficiently under legislative and regulatory mandates and clinical and administrative policies and guidelines.
Description of Job
About the Position:
This position assists with the implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 25-3-109. This position reviews and analyzes incident reports, using the standards of practice set by the Colorado Department of Public Health and Environment (CDPHE), and provides follow up for Colorado Mental Health Institute at Pueblo (CMHHIP), Office of Behavioral Health (OBH), and Colorado Department of Human Services (CDHS). Additionally this position investigates and determines which events constitute a critical incident/occurrence and determines which of those must be reported to Executive Management in Denver, CMHHIP leadership, including the hospital CEO and the Deputy Director of Clinical Services for OBH and Colorado Department of Public Health and Environment (CDPHE). Additional duties in this position include:
Critical Incident/ Occurrence Investigation and Reporting
- Ongoing development and implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 25-3-109
- Collects, analyzes and reports data related to hospital-wide incidents in order to improve patient and staff safety. After investigating the incident and assessing the data collected, determines which events constitute an occurrence that must be reported through the iNotify database to Executive Management in Denver, CMHHIP/OBH leadership, including the hospital CEO and the Deputy Director of Clinical Services for OBH
- Investigates and conducts mini root cause analyses into the incidents to further determine which incidents rise to the level of required reporting to the Colorado Department of Public Health and Environment (CDPHE) or the Joint Commission (TJC) as a Sentinel Event
- Investigates and develops follow-up reports on any occurrence that meets the criteria, which includes, but is not limited to, visual review of video footage, performing interviews alone with staff and patients, recording interviews, listening to recordings, searching areas of the hospital, entering patient care areas and reviewing documentation
- Involved in the completion of Apparent Cause Analysis and Root Cause Analysis for critical incidents investigations
- Required to complete emergency physical intervention/restraint training (CTI) and CPR
- Collaborates with and advises Program and Unit Leadership, Department of Public Safety and Department Heads to respond to and investigate serious allegations that may require immediate response of an appointing authority to determine and develop an appropriate action to keep patients safe at all times
- Formulates recommendations for change or improvement in operating procedures.
Medical Records Audits and Audit Monitoring:
- Completes audits under the direction and in collaboration with the Quality Management QAPI team
- Collects and summarizes findings by aggregating data per regulatory guidelines
- Reports findings to the Director of Quality Management, and QAPI Supervisor.
- Assists with completing data input and collaborates on system maintenance for Quality Management spreadsheets and databases for audits, focused audits or focused audits requested by legitimate special interest entities affiliated with CMHHIP and TJC Tracers
- Assists in determining the best method of data presentation based on the intended audience
- Uses an established database in which results of all audits are maintained and through which comprehensive reports (including graphs and charts) may be extracted for the Director of Quality Management, Executive Committee or Program and Department Heads
- Maintains a system for tracking chart delinquencies with a goal of no delinquencies older than 30 days hospital-wide
- Monitors delinquencies and works with clinical staff to correct them within established timelines
- Coordinates resolution of delinquencies with Quality Management QAPI team
- Provides reports on delinquencies to the Director of Quality Management and Quality Management QAPI supervisor
- As part of the utilization management program, this position may be asked to participate in various aspects of utilization review. For example, compose clinical letters in reply to third-party payer denial for reimbursement, and auditing the medical record to determine if there is additional documentation to be included to support medical necessity.
Under direction of the Quality Management Director:
- provides back-up support in the Tracer process, which mimics the tracer methodology employed by the Joint Commission when they conduct on-site surveys for themselves and CMS
- Uses knowledge of Joint Commission and CMS Standards to complete intense observation of all areas, to include patient care areas, assessing environment of care, patient-staff interactions, observation of medication administration, seclusion and restraint, programming, plan of care reviews etc. It also involves detailed audits of medical records on each unit visited to ascertain compliance with Joint Commission/CMS Standards
- Tracers also review ancillary services such as Radiology, Clinics, and Physical Therapy etc. This position specifically reviews Ambulatory Care Services, Physical Therapy, Dental Services and Radiology
- Responsibility to perform assigned tasks and duties within the scope of practice for this position that do not fall within the realm of duty statements A-C to meet the vision and mission of the agency and/or the department.
Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights
Six (6) years of relevant experience in a behavioral health, clinical or hospital setting
OR
A combination of related education and relevant experience in a behavioral health, clinical or hospital setting equal to six (6) years
Preferred Qualifications:
- Previous State Experience
- Bachelor's degree or higher in the clinical field of Counseling, Psychology, Nursing, or Social Work.
- Behavioral health experience
- Experience investigating occurrences
- Prior utilization management experience
- Experience in writing professional reports
- Prior experience interacting with regulatory entities
- Previous experience in quality improvement measures
- Data collection and analysis
- Full Background - Name check, TRAILS, Drug Screen and Fingerprinting
- Critical Services Designation - Employees in critical positions can be expected to work and/or remain at their worksite in delayed start, early release or closure situations
- Former State employees who were disciplinarily terminated or resigned in lieu of termination must disclose the information on the application and provide an explanation why the prior termination or resignation should not disqualify the applicant from the current position. Absent extraordinary circumstances, prior disciplinary termination or resignation in lieu of termination will disqualify the applicant from future State employment with CDHS
- Up to-date on MANDT and CPR prior to working first assignment
- Able to: Lift arms above head and kick as high as own waist
- Stabilize another person to accomplish a controlled take down
- Rotate body 90 degrees with feet planted for using a defensive tactic
- Kneel on one or both knees and stand up again with multiple repetitions
- Must be able to see and hear in order to observe, address and respond to potential breaches in safety
- Seize, hold, control or subdue violent or assaultive persons and defend oneself or others to prevent injury
- Demonstrate body agility, strength of all four limbs and the ability to walk and climb stairs consistently
- Work in situations involving assaultive behavior, physical control of another person and/or restraint situations.
- Shall not initiate or engage in sexual, social, personal or financial relationships with patients either during or any time after hospitalization, even if the patient requests or initiates such a relationship. All relationships with current or former patients must be disclosed on your application
- Successfully pass all modules of the CMHHIP New Employee Orientation core curriculum to include English reading comprehension, relevant competency assessments and written/practical exams
- Has direct patient care responsibilities; work in situations involving assaultive behavior
- Ability to read and comprehend the English language; effectively and fluently communicates in English, both verbally and in writing
- 2-step TB (tuberculosis) screening is required of all new employees upon hire
- Annual influenza and other vaccinations as required
Appeal Rights:
If you receive notice that you have been eliminated from consideration for the position, you may protest the action by filing an appeal with the State Personnel Board/State Personnel Director within 10 days from the date you receive notice of the elimination.
Also, if you wish to challenge the selection and comparative analysis process, you may file an appeal with the State Personnel Board/State Personnel Director within 10 days from the receipt of notice or knowledge of the action you are challenging.
Refer to Chapters 4 and 8 of the State Personnel Board Rules and Personnel Director's Administrative Procedures, 4 CCR 801, for more information about the appeals process. The State Personnel Board Rules and Personnel Director's Administrative Procedures are available at www.colorado.gov/spb.
A standard appeal form is available at: www.colorado.gov/spb. If you appeal, your appeal must be submitted in writing on the official appeal form, signed by you or your representative, and received at the following address within 10 days of your receipt of notice or knowledge of the action: Colorado State Personnel Board/State Personnel Director, Attn: Appeals Processing, 1525 Sherman Street, 4th Floor, Denver, CO 80203. Fax: 303-866-5038. Phone: 303-866-3300. The ten-day deadline and these appeal procedures also apply to all charges of discrimination.
Supplemental Information
About Us:
- Strong, secure, yet flexible retirement benefits including a PERA Defined Benefit Plan or PERA Defined Contribution Plan www.copera.org plus 401(k) and 457 plans
- Medical and dental health plans
- Employer supplemented Health Savings Account
- Paid life insurance
- Short- and long-term disability coverage
- 11 paid holidays per year plus vacation and sick leave
- BenefitHub state employee discount program
- Employee Wellness program
- Excellent work-life programs, such as flexible schedules, training and more
Remote work arrangements for eligible positions
Some positions may qualify for the Public Service Loan Forgiveness Program. For more
Our Values:
We believe in a people-first approach: To serve the people of Colorado, we develop a culture and work environment that creates an energized, inspired, and healthy team capable of giving their best to Coloradans.
Balance creates quality of life: We want our team to be resilient through a supportive workplace that values flexibility, health and wellness, and employee engagement.
We hold ourselves accountable: We take responsibility through our actions, programs, and results for the state of health and human services in Colorado.
Transparency matters: We are open and honest with employees, our partners, the Coloradans we serve, and the public.
We are ethical: We abide by what is best for those we serve by doing what is right, not what is easy.
Collaboration helps us rise together: We work together with all partners, employees, and clients to achieve the best outcomes for Coloradans.
We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore, we encourage responses from people of diverse backgrounds and abilities.
ADAA Accommodations: CDHS is committed to the full inclusion of all qualified individuals. As part of this commitment, our agency will assist individuals who have a disability with any reasonable accommodation requests related to employment, including completing the application process, interviewing, completing any pre-employment testing, participating in the employee selection process, and/or to perform essential job functions where the requested accommodation does not impose an undue hardship. If you have a disability and require reasonable accommodation to ensure you have a positive experience applying or interviewing for this position, please direct your inquiries to our ADAA Coordinator, Nancy Schmelzer, at cdhs_ada@state.co.us or call 1-800-929-0791.
~THE STATE OF COLORADO IS AN EQUAL OPPORTUNITY EMPLOYER~
