Job Summary
The Director of Quality Management is responsible for leading the organization's Quality Management Program by ensuring regulatory compliance, accreditation readiness, patient safety, risk management, and continuous performance improvement across all service lines. This position collaborates with leadership to promote a culture of quality, accountability, and excellence in patient care. The Director of Quality Management reports directly to CEO.
Essential Job Duties
Regulatory Compliance & Accreditation
- Lead all quality management activities across the organization.
- Maintain ongoing compliance with CARF, CMS, state licensing, DEA, OSHA, HIPAA, and other applicable regulatory agencies.
- Coordinate accreditation surveys and regulatory inspections.
- Ensure corrective action plans are developed, implemented, and monitored.
Performance Improvement
- Develop and oversee the organization's Performance Improvement (PI) Program.
- Establish quality indicators and monitor key performance metrics.
- Analyze trends and recommend operational improvements.
- Facilitate Performance Improvement Committee meetings.
Clinical Quality Oversight
- Conduct routine clinical chart audits.
- Monitor documentation quality and regulatory compliance.
- Collaborate with clinical leadership to improve patient outcomes.
- Ensure treatment plans and clinical documentation meet established standards.
Incident & Risk Management
- Oversee the incident reporting system.
- Trend and analyze patient safety events.
- Conduct root cause analyses when appropriate.
- Recommend risk mitigation strategies.
- Monitor grievances, complaints, and patient satisfaction.
Data Analysis & Reporting
- Develop quality dashboards.
- Prepare monthly and quarterly quality reports for executive leadership and the Board.
- Monitor:
- Readmission rates
- AMA rates
- Length of stay
- Patient satisfaction
- Clinical outcomes
- Productivity measures
- Regulatory findings
Policy & Procedure Management
- Maintain organizational policies and procedures.
- Ensure policies remain compliant with current regulations.
- Coordinate annual policy reviews.
Education & Training
- Provide quality and compliance education to staff.
- Conduct orientation regarding quality initiatives.
- Educate departments on regulatory changes and best practices.
Leadership & Collaboration
- Chair or participate in Quality Management Committee meetings.
- Collaborate with Medical Staff, Nursing, Operations, Human Resources, and Finance.
- Serve as the organization's quality resource during strategic initiatives.
Qualifications
- Active RN license.
- Previous quality management experience required.
- Behavioral health, substance use disorder, or psychiatric healthcare experience strongly preferred.
- Experience with CARF accreditation highly preferred.
- Knowledge of CMS Conditions of Participation, HIPAA, OSHA, and state licensing requirements.
- Strong analytical, organizational, and leadership skills.
- Proficiency with Microsoft Office and quality reporting tools.
Key Performance Indicators (KPIs)
- Successful CARF and regulatory survey outcomes.
- Reduction in documentation deficiencies.
- Improvement in patient outcome measures.
- Reduction in incident trends and patient safety events.
- Timely completion of corrective action plans.
- Increased compliance audit scores.
- Improved patient satisfaction.
- Reduction in AMA rates.
- Completion of quality improvement projects on schedule.
Responsibilities
- Develop, implement, and monitor comprehensive quality management strategies aligned with healthcare regulations such as CMS, JCAHO, FDA regulations, and accreditation standards.
- Lead efforts in compliance management by ensuring adherence to HIPAA privacy rules, ICD-10/ICD coding standards, CPT coding practices, and medical law requirements.
- Oversee the review and analysis of clinical data to identify trends, areas for improvement, and opportunities for process enhancement using data analysis skills and EMR/EHR systems.
- Manage risk management initiatives by evaluating potential safety issues and implementing corrective actions to mitigate liability.
- Collaborate with multidisciplinary teams to establish quality improvement projects focused on patient safety, care outcomes, and operational efficiency.
- Ensure staff training on healthcare compliance policies, Medicare regulations, managed care protocols, and healthcare regulation policies.
- Maintain up-to-date knowledge of CMS regulatory compliance requirements and accreditation standards such as JCAHO to ensure organizational readiness for audits and inspections.
- Lead team efforts in process improvement initiatives utilizing project management techniques to streamline workflows and enhance service delivery.
- AMAP RN supervision.
Join us in shaping the future of healthcare quality! We are committed to fostering an inclusive environment where your expertise can make a meaningful impact on patient care excellence while advancing your professional growth in a vibrant organization dedicated to integrity and innovation.
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
