Quality Assurance Manager

The Recovery from Addictions Program (RAP), operated by the Department of Mental Health (DMH) is seeking an experienced and qualified professional to provide leadership in the assessment of inpatient services and practices utilizing quality measures, Joint Commission standards of Care, Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and DMH regulations. The selected candidate will display excellent skills in establishing measures of care, analyzing, presenting data, and collaborating with colleagues to ensure quality oversight is integrated into all aspects of the Program’s operations and an integral component of RAP’s Performance Improvement (PI) process throughout the facility.

The Quality Assurance Manager requires excellent observational skills, competencies in problem identification and definition, capacities to collaborate with work groups in order to develop and implement solutions, and values facilitation of team problem-solving toward delivery of safe and high-quality care for individuals with mental health and substance use. RAP is a 120 bed Addictions Program with 45 beds dedicated to women and 75 beds dedicated to men.

The program is certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) as an Opioid Treatment Program and is accredited by the Joint Commission, under their Behavior Health Standards.

Please note: The work schedule will be 40 hours per week working Monday through Friday 8:00am to 4:30pm. The days off will be Sunday and Saturday.

• Oversees and coordinates quality management activities to ensure DMH standardized processes, workflows, protocols specific to the RAP units are integrated into the programs’ systems.
• Establishes and maintains open communication with and works collaboratively with the Assistant Director, safety committee and department directors.
• Updates, maintains, and reviews reports; ensures that all data and records are correct and reported.
• Produces reports and benchmark data for key stakeholders and shares findings;
  Utilizes data to develop recommendations and best practices for improvement.
• Remains current with new standards or statutes from regulatory agencies such as SAMHSA, the Joint Commission and CMS;
  Develops strategies to ensure RAP’s policies and practices are compliant.
• Meets regularly with the Human Rights Officer, Risk Manager and Director of Nursing to review patient complaints and incidents, assign, and refer fact findings to relevant investigatory bodies.
• Identifies processes and procedures that support quality and safe patient care as well as those process that contribute to patient and staff safety concerns.
• Develops and implements the Quality Management Department’s annual plan that is reviewed and approved by the Executive Committee.
• Provides supervision to Utilization Review, Risk Management, and administrative support staff.
• Consults with staff as necessary to obtain information necessary to complete fact findings for complaints and reports.
• Provides orientation and annual review training to facility employees regarding the facility Quality Management Program.
• Works collaboratively with performance improvement leaders; assists with performance improvement projects.
• Supports all HIPPA Compliance and ongoing audits.

• At least two (2) years supervisory administration of managerial experience.
• Prior experience working in a quality and/or performance and process improvement role.
• Comprehensive knowledge and skills of Quality Improvement Processes and Tools.
• Demonstrated practice in understanding and communicating how operational and clinical outcomes foster organizational strategy and growth.
• Skilled in strong, effective communication, statistical interpretation, and development of positive/productive working relationships.
• Knowledge of TJC, SAMHSA, CMS Conditions of Participation and regulatory agencies requirements for quality improvement and patient safety.
• Ability to identify and analyze trends, complete reports, and make recommendations for actions based on analysis.
• Capacity to promote…