Vice Persident of Quality Assurance and Performance Improvement

Job Title: Vice President of Quality Assurance and Performance Improvement
Reports To: Chief Executive Officer
Type: Full-Time
Location: Administration

I. Purpose

Vice President of Quality Assurance and Performance Improvement, under the supervision of the Chief Executive Officer, is responsible for the activities of performance improvement and planning, including but not limited to all quality management activities, corporate compliance, privacy protection, utilization management activities, accreditation, the Quality Management & Performance Improvement (QM/PI) Committee structure, and organizational planning. Working closely with Executive Management Team members, the person in this position takes a leadership role on initiatives related to quality and performance improvement, accreditation and regulatory requirements. Vice President of Quality Assurance and Performance Improvement The Quality & Compliance Vice President serves as The Havens Privacy Officer. Maintains a direct reporting relationship to the Board of Directors for compliance related issues Directors. The Haven endorses a trauma-informed care approach and a medical model of SUD treatment.

II. Essential Functions

The essential functions of the Vice President of Quality Assurance and Performance Improvement are:

Develops, monitors, and reviews agency performance improvement and planning including The Havens quality and utilization management plan(s) and processes in accordance with the rules and regulations of funding, accrediting/licensing agencies and internal policies and procedures.
Serves as the organizations Corporate Compliance Officer and prepares regular and ad hoc training reports regarding compliance issues.
Serves as The Havens Privacy Officer.
Leads the organizations quality & compliance operations and ensures that the management and the Board of Directors have a clear understanding of operating performance, risk mitigation to assure alignment with the organizations strategic goals.
Chairs The Havens QM/PI Committee.
Manages agency planning efforts including agency strategic and operational plans, QM plan, Corporate Compliance Plan, Accessibility Plan and other required plans as per the framework established through various relevant contracts.
Oversight of the Committees structured under Quality Management Program to assure that the Principles, Plans, People, Processes, Metrics, Improvers, and Rewards are aligned with the important priorities of the agency.
For Risk Management Committee, track and assess organizational risks; assess adequacy of The Havens regulatory policies to meet licensing and funding requirements as well as the organizations evolving needs, as indicated.
Oversees timely reporting of all incidents, accidents, and deaths to regulatory bodies.
Oversee and monitor the receipt and execution of subpoenas/court orders while assuring legality of releases of information, and protection of health information. (HIPAA)
Identify potential compliance issues, as needed, investigates issues, complaints, tips, and presents findings. Assists in the oversight of risk management efforts.
Monitors trends regarding compliance and communicates these as appropriate to the Executive Management Team (EMT) and the Board.
Coordinates and facilitates all agency-wide accreditation efforts including maintaining CARF accreditation.
Assists in the oversight of ensuring that staff meets and maintains requirements consistent with accreditation and funding source standards.
Responsible for the development and reporting of measures of agency efficiency and effectiveness.
Responsible for administrative oversight of The Havens Health & Safety Committee.
Oversees development and maintenance of agency policies and procedures. Prepares reports as necessary.
Ensures that performance improvement activities are consistent with agency funding source requirements.
Oversees the reviews and responses to external agencies regarding inquiries involving serious incidents including mortalities, member services and complaints.
Investigates critical incidents, Notice of Concerns, and Quality of Care Concerns and prepare reports/responses of findings.
Monitors and facilitates the responses for Grievances and Appeals.
Provides training and technical assistance to agency staff and subcontracted providers.
Assures consistent audit and review processes (internal and external) occur; ensure that information regarding audit results gets to the appropriate individuals in order to meet clinical standards of the agency and appropriate funding, licensing, and accreditation agencies.
Monitors agency sites for compliance with ADHS, CARF and safety standards and reports results to applicable sites and internal committees.
Attends and participates in Executive Management Meetings, Key Leadership Meetings and other meetings as appropriate.
Attends payor and other external meetings, as necessary, to receive input and communicate information relevant to program quality and agency performance improvement operations.
Supervises and provides coaching to assigned staff.
Facilitates Quality Management/Performance Improvement workgroups.
Collaborates with clinical teams to lead program improvement initiatives, identify gaps in clinical and operational quality processes, and develop sustainable, evidence-based solutions.
Responsible for overseeing the maintenance of licensure of agency facilities. Completes provider site reviews and assures compliance with contracting requirements.
Adheres to company, federal, state, and local business requirements, enforcing compliance and taking action when necessary.
With the Sr. Vice President of Finance & Administrative, assists in the annual preparation of the Quality and Compliance budget for review and approval by the board of directors. Monitors and manages the income and expenditures to keep agency expenditures within budget.
Reviews fidelity of evidence-based practices and ensures overall compliance with contracts, regulatory agencies and accreditation processes.
Assists staff with data collection instruments and timelines, statistical reporting, and graphical representations of data.
Supervises the Quality Management Analyst and Compliance Coordinator. Monitors and reports on status of implementation of effective staff trainings which increases the quality of services provided.
Coordination, preparation and assistance with internal and external audits
Audits staffs clinical documentation and provides training regarding all contract requirements.
Designs and conducts special projects as needed.
Performs related duties as assigned in accordance with agency growth and change.

III. Qualifications

Education & Experience

Masters degree from a qualified, nationally accredited program, or an equivalent combination of relevant education, and Compliance and QM experience; Master of Social Work, Counseling, or related field preferred.
Certified Professional in Healthcare Quality (CPHQ) and/or Certified in Healthcare Compliance (CHC) or Certified in Healthcare Privacy Compliance (CHPC) certification preferred.
A background in quality, database, or system management experience is preferred.
At least seven years of experience in behavioral health care operations.
Supervisory experience preferred.
A valid Drivers License with a clean driving record is required.
Must have an Arizona Non-IVP Level-1 Fingerprint Clearance Card at the time of hire and maintain it during employment.
Must have current CPR and First Aide Certification or be able to obtain within 30 days of hire.
Must have current Non-Violent Crisis Intervention or be able to obtain within 30 days of hire.

Knowledge/Skills/Abilities

Demonstrates knowledge and ability to create databases, forms and reporting systems and can draw conclusions and make recommendations based on data.
Tracks details with meticulous accuracy.
Knowledge of behavioral health principles and practices.
Appropriately utilizes quality management principles and practices.
Demonstrates knowledge and understanding of therapeutic programs and activities, as related to substance use and co-occurring disorders, and prevention services for adults and children.
Demonstrates knowledge of state and federal requirements of in the areas of corporate compliance, quality assurance/utilization management.
Demonstrates knowledge of state licensure and accreditation standards under OBHL, AHCCCS, health plans, and CARF.
Demonstrates knowledge of the principles of Corporate Compliance and Health Record Privacy Protection.
Demonstrates ability to analyze specifications and instructions and develop logical formatting, which ensures proper presentation of information.
Effectively works with providers and internal staff to resolve issues.
Ability to communicate effectively orally and in writing.
Ability to interact and provide effective leadership in a team setting with other behavioral health professionals.
Demonstrates skill in planning, organizing, and coordinating activities relating to performance improvement.
Considerable knowledge of administrative practices and procedures. Exhibits the ability to work independently and to exercise considerable independent judgment.
Works efficiently and meets a variety of deadlines without oversight.
Exhibits adaptability to changing environments and new technologies.
Demonstrates ability to understand informational flows and the impact on current and future events.
Evaluates, selects and acts on various methods and strategies for solving problems and meeting objectives before being asked or required to do so; self-directed rather than passively complying with instructions or assignments.
Skills in area of supervision and management as they relate to program operations.
Ability to establish and maintain accurate records.
Demonstrates knowledge of and appreciation of cultural differences.
Demonstrates effective communications and relationship building.
Demonstrates effective supervision of staff.
Demonstrates effective leadership skills.
Demonstrates effective business and administration skills.
Demonstrates effective project management abilities.
Demonstrates clinical competency in accordance with standards for the position.
Knowledge of adult learning principles
Extensive knowledge of community resources
Intermediate to advanced computer skills using MS Office products, Word, Excel and ability to import/export date to/from applications.
Must possess good customer service skills.

IV. Extent of Public Contact

Interacts with external entities, with all levels of Haven personnel, the Board of Directors, and with Haven members.