Safe Harbor Recovery Center · 5 hours ago
Director of Quality & PI
Portsmouth, VA
Full-time
Onsite
Lead/Staff, Director/Executive
3+ years expSafe Harbor Recovery Center is seeking a Director of Quality and Performance Improvement to ensure compliance with various regulations and improve client safety and quality of care. The role involves directing quality management operations, coordinating regulatory activities, and leading a team to enhance clinical programs and compliance processes.
Mental Health Care
Responsibilities
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 facility 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, certification and accreditation (OHFLAC, BHHF, CMS, Joint Commission, CARF, ASAM, 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 in assigned facilities
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 and improvement of services
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 a broad vision in the strategic development and direction of the performance improvement program for the facility. Develops a facility-wide performance improvement plan and PI tools
Develops processes for identification, collection and analysis of performance measurement data. Utilizes collected data regarding the outcome of activities for delivering continuously improving services
Determines if services meet pre-determined quality improvement expectations and outcomes. Develops written plans to improve and/or correct quality, safety and appropriateness of client care. Conducts routine evaluations of the effectiveness of services
Ensures correction of any observed deficiencies identified through the quality improvement process
Conducts timely and regular evaluation of serious incidents, complaints, grievances and related investigations
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
Develops and implements program policies and procedures that guide the provision of services
Complies with organizational policies, procedures, performance improvement initiatives and maintains regulatory and industry standards
Maintains regular and reliable attendance
Accepts responsibility for professional growth and development of self and attends all mandatory facility in-services and staff development activities as scheduled
Maintains professionalism and confidentiality of facility employees and patients
Performs other duties as assigned
Qualification
Required
Bachelor's Degree with a clinical, nursing, or business emphasis required
Three or more years' experience in Quality Management, PI role, facility licensure, survey and credentialing process required
Professional clinical license issued by the appropriate licensing body as required by the state
CPR and de-escalation certification required (training available upon hire and offered by facility)
Two years' supervisory/management experience required if supervising team members
Preferred
Master's Degree in Human Services preferred
Experience in a behavioral health setting preferred
Experience with TJC and/or CARF accreditation and regulatory audits preferred
Two years' supervisory/management experience preferred if a standalone position with no supervision responsibilities
Benefits
Comprehensive benefit plan
Company
Safe Harbor Recovery Center
Safe Harbor Recovery Center, located in Portsmouth, Virginia, provides a safe, structured environment for men and women struggling with a substance use disorder.
11-50 employees
Funding
Current Stage
Early StageLeadership Team
April Green, LCSW, BCD
Chief Executive Officer
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