Purpose:

Directs Quality Management and Improvement initiatives within Wyandot BHN and its family of organizations; manages data collection and reporting; provides oversight to managing and implementing the agency utilization review of clinical services and documentation; ensures policy development/implementation and adherence to expectations; plans and implements systems to manage compliance with internal and external standards and regulations, including managed care authorizations; serves as liaison with licensing and certification entities; directs, leads, and manages CARF certification; oversees the administration and management of medical records and quality management staff; serves as the Corporate Compliance Officer; and serves as a member of the Executive Leadership Team.

Accountabilities:

Quality Management & Improvement

• Develop and implement annual and quarterly strategic quality goals and objectives for the agency.
• Oversee the collection and reporting of data for improvement and monitoring achievement of agency goals
• Lead agency Quality Management & Improvement Committee
• Oversee record audits to ensure compliance with funding and licensing regulations and quality standards.
• Develop systems and procedures to monitor conformity to standards and quality improvement.
• Develop and use tools to train staff on improving the accuracy, quality and efficiency of agency programs.
• Develops, monitors and assesses risk management
• Oversee the review of all critical incident reports.
• Provide oversite to all sentinel event reviews.
• Monitor functioning and performance analytics.

Licensing, certification, and accreditation with KDADS and CARF

• Serve as liaison with licensing and certification entities
• Ensure CMHC licensing, CCBHC certification, and CARF accreditation requirements are met.
• Develop and manage Quality Improvement plans in collaboration with clinical leadership.
• Ensure adherence and compliance to licensing, certification, and accreditation standards.
• Monitor and measure progress/status annually.
• Produce reports and provide updates.

Corporate Compliance

• Provide day-to-day guidance to organization regarding compliance and risk management.
• Ensure the organization is in compliance with HIPAA and state privacy regulations.
• Act as agency privacy officer.
• Conducts corporate compliance investigations and makes recommendations
• Develops and disseminates policies and procedures regarding all compliance related activities.
• Communicate with CEO, Board Chair and Organization’s Attorney regarding corporate compliance.
• Work with training department to ensure employees are trained and educated regarding corporate compliance
• Reports compliance issues to the appropriate agencies in collaboration with the CEO and as appropriate.
• Responsible for writing, reviewing and editing policies and procedures.

Staff Management/Development

• Directs the functions of staff.

Ensures accurate and timely completion of tasks.

Manages the planning and coordination of activities.

Trains and provide coaching in work assignments (demonstrating ‘how to’ on task completion, providing guidance, offering constructive feedback, answering questions, etc.)

• Oversee the day-to-day administration and management of staff.

Directs staff activities (guiding toward optimal performance, participating/overseeing managerial processes [interviewing, selection, staff development and/or performance, discipline actions, etc.], conducting team meetings, preparing/conducting performance evaluations, ensuring adherence to policies, practices, and protocols [organization and/or regulatory compliance], assisting with problems [personnel issues, conflict resolution, crisis management, etc.], etc.).

Proactively enhances and improves efficiencies (assessing performance, evaluating/needs/services, providing educational enrichment opportunities to direct reports, ensuring optimal utilization of facilities and resources, maintaining confidentiality, etc.).

o Oversee the maintenance of personnel recordkeeping [vacation, holiday, sick time, etc.] monitoring activities, recording absences, directing the updating of files, etc.

Qualifications:

Education: Master’s degree in mental health care discipline or business/management field. Must be licensed by the Kansas Behavioral Sciences Regulatory Board.

Experience: Minimum of five years of related experience, e.g., working for a community mental health organization or in some capacity of Psychology, Marriage & Family, Social Work, or Mental Health Counseling. Knowledge of licensing and regulatory

requirements for CMHC/CCBHC. Previous quality management and supervisory experience preferred.

Skills/Abilities:

· Excellent communication skills (oral/written).

· Working knowledge of standard concepts, practices, procedures and regulations of behavioral healthcare industry, including state and federal requirements.

· Knowledge of community mental health services in Kansas.

· Ability to analyze data, generate reports and recommend strategies that reflect an adherence to standards, outcomes, and efficiency to resource applications.

· Demonstrated ability to work with highest level of confidentiality and business ethics in relation to organizational systems access.

· Working knowledge of roles of various regulatory agencies affecting the functioning of a community-based service organization.

· Familiarity and knowledge of data reporting systems for Kansas mental health providers.

· Demonstrated ability to work in a collaborative environment; ability to work as a business partner with all departments/functions and use organizational goals, philosophy, mission, vision and values as operating drivers in all recommendations and decisions.

· Ability to manage priorities and maintain expected progress with a variety of assignments.

· Must have innovative solutions to ensure continuous quality improvement.

· Ability to evaluate and assess effectiveness of improvement tools and processes, making recommendations to further advance the organization.

· Must be able to safely perform essential job functions, with or without reasonable accommodation.

Location/Travel/Work Conditions and Considerations:

Works from a central office and travels to other Center locations. May require non-routine business hours based on agency need. May require additional travel for meetings and conferences.