Vice President of Quality Management & Improvement

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.

• 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.

• 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.

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

• 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.