Empower Every New Yorker - Without Exception - to Live the Healthiest Life Possible

NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city's five boroughs. Our large health system consists of ambulatory centers, acute care centers, post-acute care/long-term care, rehabilitation programs, Home Care, and Correctional Health Services. Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

Under supervision of the Central Office/Office of Behavioral Health Medical Director of Behavioral Health Core Clinical Services or their designee, will develop, plan, coordinate and monitor the professional and medical aspects related to the delivery of behavioral health care services delivered at the Health + Hospitals (H+H) facilities, and assure the maintenance and attainment of quality care as mandated under Federal, State and local regulations and standards. In collaboration with the Medical Director of Behavioral Health Core Clinical Services, Quality Management leadership at H+H Central Office, and the Quality Management departments at H+H facilities, formulates, helps execute, and evaluates quality improvement programs and projects in behavioral health for the system.

SPECIFIC TASKS AND RESPONSIBILITES:

System-wide Quality Activities

• Formulates and develops methods and procedures for monitoring and evaluating implementation and maintenance of health care standards to assure attainment of quality care and excellent patient experiences, and to meet mandated legislative, regulatory, and administrative standards.
• Monitors and coordinates the review processes of assigned programs for health care standards and service programs to determine if programs are meeting the health care needs, objectives and goals of policies and procedural guidelines.
• Develops operating policies for adherence to broad policies and objectives of Utilization Review Programs and Professional Standards Review Organizations.
• Coordinates functional activities of the Health Care Standards with other Corporate organizational units and maintains liaison with internal and external sources and with key officials.
• Reviews evidence-based models and designs for health care delivery systems to assure delivery of quality care standards.
• Provides guidance to health care facilities for establishment and maintenance of utilization review, quality assurance and discharge planning programs which conform to State, Federal and Joint Commission (TJC) requirements and advises to resolve operating problems.
• Reviews City, State and Federal regulations and TJC standards relating to compliance reviews and surveys and advises behavioral health clinical and quality leadership at facilities on how to improve programs for full compliance. Advises on upcoming regulatory and TJC standards changes, and required actions needed to meet or exceed new industry standards and to achieve improved outcomes.
• Develops and evaluates training programs for in-service training and professional development of hospital-based personnel where activities relate to utilization review, PSRO organizations and health care standards programs.
• Designs and monitors evaluation activities relating to quantity and quality of H+H data related to behavioral health quality.
• Designs and/or reviews performance audits and performance improvement activities, and makes recommendations to improve effectiveness and to assess quality standards of health care delivery.
• Advises Medical Director of Behavioral Health Core Clinical Services on policy and procedural changes and makes recommendations for improvements in design of health care standards programs.
• Participates in meetings, may plan conferences, seminars with health care groups, medical and professional health care organizations and hospital medical authorities related to special medical programs, health care standards and practices.
• Interpret the efficacy of treatment to which care for clients is accomplished via outcome and other quality metrics.
• Ensures safe delivery of services by evaluating the safety and efficacy of care. Participates in H+H Central Office safety and incident review processes.
• Evaluates the efficiency of processes and/or the relationships between and outcomes and resources used.
• Aligns fiscal constraints with performance improvement activities.
• Identifies new/revised potential regulatory requirements and TJC standards and suggest policies/procedures to ensure compliance.
• Establishes and maintains mechanisms to periodically review treatment outcome objectives.
• Coordinates the collection, validation, and analysis of all data related to behavioral health quality indicators and utilizes findings to drive improvements, mitigate risks, and to increase the level of care within the System.
• Collaborates with OBH and facility leadership to develop Quality Assurance Policy and Procedures.
• Develops reports which regularly (eg., quarterly) summarize various metrics, such as incidents and outcomes.
• In-Services facility leadership and OBH staff to any revisions or actions related to Quality Assurance policies and procedures.

Social Work Training Academy Quality Activities

• Design and develop training evaluations and assessment tools to measure the overall effectiveness and impact of training provided by the SW Training Academy.
• Implement methods to collect data on learning experiences and knowledge acquisition.
• Establish pathways to obtain feedback from training participants with the aim of identifying areas of needed enhancement and collaborate with training staff to facilitate data-driven improvements to training delivery.

Minimum Qualifications
1. Master's degree from an accredited college or university in Quality Management, Hospital Administration, Health Care Administration, or in a related health care specialization; and five (5) years of experience in the development of organizational strategies and implementation of staffing plans, regulatory survey preparation and compliance, and in performance improvement and/or continuous quality improvement (CQI) initiatives in a hospital or health care setting, three (3) years of which must have been in a responsible administrative,
managerial or supervisory capacity; or,
2. Bachelor's degree in the disciplines as described in "1" above; and seven (7) years of related experience, as listed in "1" above, five (5) years of which must have been in a responsible administrative, managerial or supervisory capacity; or,
3. Bachelor's degree in the disciplines as described in "1" above; and two (2) years of clinical, patient care or equivalent experience in a hospital or health care setting, plus three (3) years of related experience, as listed in "1" above, one (1) year of which must have been in a responsible administrative, managerial or supervisory capacity; or
4. A satisfactory equivalent of education, training, and/or experience. Certified Professional in Healthcare Quality (CPHQ) may be substituted for one (1) year of experience, however, all incumbents must have at least a bachelor's degree and one (1) year of responsible administrative, managerial or supervisory experience, as described in "1" above.

Department Preferences

• Must have strong administrative and organizational skills.
• Knowledge of clinical practices related to Behavioral Health and Hospital services.
• Knowledge of standards of care and best practices.
• Knowledge of hospital systems and community resources.
• Knowledge of federal, state, local, H+H standards, regulations, guidelines, policies and procedures.
• Knowledge of Substance Use/Addiction: behaviors, interventions and resources.
• Knowledge of H+H policies and procedures regarding Human Resources and Labor Relations.
• Knowledge of Joint Commission and CMS standards of care.
• Knowledge of NYS Mental Hygiene Law and Regulation.
• Knowledge of NYC DOHMH, NYS OASAS, NYS OMH and Joint Commission guidelines, regulations, and standards.
• Knowledge of Code 405 Title 18

If applying online, please include your cover letter in the same file attachment with your uploaded resume.

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs