Manager, Service Line Quality (Behavioral Health)

Description:
JOB PURPOSE:
Develops and implements programs and efforts needed to support a comprehensive quality management and process improvement program for emerging and/or established service line. Prioritizes patient safety efforts and quality of care strategies to improve patient outcomes. Aligns efforts between service line functions, entity needs, and PHC safety and quality. Maintains current knowledge of requirements related to CMS Conditions of Participation, DNV requirements, MEC bylaws, and other internal and external regulatory needs.

KEY RESPONSIBILITIES:
1. Works with staff, physicians, and leadership to develop and maintain a comprehensive quality management program, developing policies and processes to ensure best practices that standardize clinical care and reduce practice variation.
2. Manages the development, tracking, analysis, and follow-up required for key performance indicators, objective measures, quality report cards, scorecard items, and other metrics defined by the service line.
3. Leads and participates in quality activities, committees, and work groups, and ensures adherence to required regulatory standards and organizational expectations (e.g. Clinical Governance Councils, DNV, CMS, etc.).
4. Organizes, trains, and facilitates multi-disciplinary teams to successfully implement performance improvement initiatives that achieve program quality goals.
5. Assists staff, leadership, and physicians to maintain continuous readiness for regulatory surveys (e.g. mock survey drills, and ongoing education). Keeps leadership aware of any areas of concern.
6. Serves as a liaison for regulatory and quality audits and assists with the development of materials in preparation for, and in response to, regulatory surveys.
7. Actively participates in reporting, analysis, and follow-up of risk/safety events. Develops and recommends corrective action to improve quality and patient safety when undesirable patterns or outcomes are identified.
8. Coordinates development and presentation of quality data, service line scorecards, corrective action plans, regulatory RFIs, etc.
9. Supervises the performance improvement activities of the service line to include quality management, incentive programs, quality certifications, evidence-based practice, and comparative data review.
10. Develops, implements, and sustains quality, safety, and performance improvement activities throughout defined areas for the service line.
11. Supervises activities of the concurrent review program in reviews/ management of assigned cases for peer review and quality management.
12. Identifies, builds, and reports quality metrics to various internal and external stakeholders
13. Provides guidance to subject matter experts, content developers, and content editors related to topic selection, content planning, instructional design, development, and implementation of educational activities.
Qualifications:
MINIMUM EDUCATION REQUIRED:
Bachelors degree required.

MINIMUM EXPERIENCE REQUIRED:
Five (5) years of experience in healthcare operations management, quality/safety, and/or performance improvement is required.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
None.

For the Behavioral Health Department:
LPC, LMSW, LCSW, LMFT or Registered RN in the state of GA is required.

ADDITIONAL QUALIFICATIONS:
Masters degree is preferred.
Working knowledge of standards, rules, regulations, and guidelines imposed by accrediting organizations and regulatory agencies.
Knowledge of quality, safety, and performance improvement strategies to improve outcomes.
Ability to foster an engaging environment while facilitating committees, work groups, and other projects. Prior experience with Epic preferred.