Quality Assurance Director

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Full Time Professional Conrad, MT, US

6 days ago Requisition

• Clinical Quality
  • Interprets and implements quality assurance standards.
  • Reviews clinical policies and procedures for quality and compliance.
  • Provides monitoring for preventive and corrective actions.
  • Identifies training needs and organize training interventions to meet quality standards.
  • Monitors risk management activities, reporting significant findings to Executive.
  • Reviewing client grievances and complaints and provides recommendations for clinical quality.
  • Development and implementation of an annual, formal, and comprehensive data-driven Continuous Quality Improvement (CQI) plan for CCBHC requirement.
  • Supports and monitors outcome measures model.
  • Reviews client and medication incident reports; recommends procedural and/or clinical policy changes.
  • Prepares Monthly Incident Review Tracking Form; reviews in Monthly Clinical Director’s meeting.
  • Facilitates proper documentation and reporting of significant incidents such as critical incidents and potential client abuse and/or neglect.
  • Collaborates on manuals to include Clinical, Program, Quality Assurance and Leadership.
• Audit/Surveys
  • Conducts and/or oversees agency and program clinical audits such as those from DPHHS, SURS, Division of Quality Assurance, VA, WICHE, etc.
  • Coordinates and supports on-site audits conducted by external agencies.
  • Prepares reports for Leadership to communicate outcomes of quality activities and develops formal written response for audits.
  • Evaluates audit findings, developing a corrective action plan with the COO and Directors, monitoring progress and completion.
  • Collaborates with Leadership regarding audit processes and results.
  • Initiates, analyzes, and prepares report regarding client surveys.
  • Completes Annual Quality Assurance Report, quarterly and annual reports.
• ARMS/Regulatory Requirements
  • Assures agency compliance with the ARMS in all clinical programs to include documentation that supports appropriate billing.
  • Assures ongoing compliance with quality and industry regulatory requirements.
  • Monitor the Administrative Rules of Montana. May train leadership and/or employees accordingly.
  • Creates policies and procedures that meet state and federal legal requirements.
• Data Management
  • Devises sampling procedures and directions for recording and reporting quality data.
  • Collects and compiles statistical quality data.
  • Responsible for document management systems.
  • Completes necessary reports and assessments in a timely manner in accordance with agency policy.
• Confidentiality Regulations
  • Designated as the agency’s HIPAA Privacy and Security Officer.
  • Conduct monitoring and investigates potential HIPAA breach violations.
  • Reporting for HIPAA violations to DPHHS.
  • Report issues pertaining to HIPAA to Leadership.
  • Supports proper documentation and processing of all HIPPA reports.
  • Completes necessary actions for correction of HIPAA concerns.
  • Submit reports of each HIPAA breach occurring within the agency to the Department of Public Health and Human Services within the first 60 days of the calendar year.
  • Reviews and approves records requests, may prepare clinical service summary letters as requested.
• Training/Education
  • Provides consultation and education services to outside agencies and the public as assigned.
  • May represent the agency in giving comments to the ARMs hearings.
  • Provides new hire orientation training on overall agency guidelines, and HIPAA/ethics.
  • Conducts HIPAA training upon request with ongoing awareness of HIPAA policies and procedures.
  • Supports leadership in identifying culturally appropriate, trauma informed evidence-based practices for programs with additional guidance to implementation of those training models and monitoring for fidelity to the model.
• CCBHC Evaluator
  • Collect and report on performance measures and Infrastructure, Prevention, and Promotion data.
  • Collect data on the clinic-level quality measures required under the CCBHC Certification Criteria and report on these data in the annual progress…