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.
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The Food and Drug Administration (FDA) is a federal agency of the United States Department of Health and Human Services, responsible for protecting and promoting public health through the control and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter pharmaceutical (medications) drugs, vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), cosmetics, veterinary products, and toxicants.