Manager, Behavioral Health Quality

Full Time

Schedule: Monday - Friday | 8:00am - 5:00pm

Job Summary: The Behavioral Health Quality Manager is responsible for the organization's performance improvement activities related to the quality of patient care and safety. Manages regulatory agency compliance functions consistent with administrative, medical staff and board approved plans. Ensures data collection and reporting meets state, federal and regulatory agency guidelines. Manages policy and procedure development to support staff training and educational activities to achieve the organization's quality of patient care standards and compliance with regulatory standards.

Minimum Education: Bachelor's degree required. Master's degree in Social Work or other clinical area preferred.

Licensure, Registration and/or Certification: Valid multi-state or State of Oklahoma Registered Nurse License, Licensed Professional Counselor (LPC), or Licensed Clinical Social Worker (LCSW), preferred.

Work Experience: 5 years of leadership experience in healthcare field, preferably in behavioral health.

Knowledge, Skills and Abilities: Ability to utilize assertiveness, political intuitiveness, and be self- motivated. Effective interpersonal, written, and oral communication skills. Ability to analyze complex issues and solve them creatively. Strong leadership skills relative to motivating and developing multi- disciplinary teams to be successful. Demonstrated training in performance improvement techniques and methods. Ability to organize and prioritize work in an effective and efficient manner.

Essential Functions and Responsibilities: Collaborate with physicians and organization leaders to design programs to improve quality and safety of patient care. Direct implementation, administration, and analysis of clinical outcomes and service data trends; compare performance to established standards; identify variances and undesirable performance; recommend and monitor strategies for improvement; report findings and make recommendations to appropriate oversight bodies, including medical executive committee, quality improvement committee, and patient safety committee. Oversee core measure abstraction and ensure timely submission. Develop, implement, and monitor hospital-wide continued readiness activities for regulatory survey preparation, follow-up, tracking and reporting to assure continual compliance with Joint Commission standards, as well as federal and state regulations such as CMS, OK DHS, OK DHS Office of Juvenile Oversight, OK Dept of Health, and ODMHSAS. Maintain accurate documentation and ensure timely submission of information as required by regulatory agencies. Oversee annual Joint Commission self-assessment process (i.e. FSA, ICM). Manage process to ensure entity specific policies and procedures are kept current and in compliance with relevant standards of care and regulations. Interfaces with Epic IT team to develop documentation and workflows to monitor and evaluate the quality and appropriateness of care furnished. This includes: intake/admissions screening, psychosocial assessment/reassessment, high social risk case finding, continuity of care, discharge planning, and exchange of appropriate information with sources outside the hospital. Collaborates closely with manager of nursing and other clinical managers to ensure staff training and educational activities ensure organization's quality of patient care standards and compliance with regulatory standards. Manages the variance reporting system in Verge, including grievances and complaints, to investigate and implement corrective action plans to improve quality. Coordinates the physician peer review process in conjunction with the executive manager and medical executive committee. Manages human and material resources. Budget plans are completed in a timely fashion with analysis of cost reduction. Continuously monitors overall utilization of resources and Manages corrective action related to fiscal management. Collaborate with entity clinical leadership and provide consultative services to other system behavioral units regarding state and federal regulations, data collection, submission and reporting. Conduct regular visits to offsite locations to ensure safety and quality processes are established. Interface with the credentialing coordinators at Warren Clinic and Saint Francis Health System to ensure hospital privileging and provider enrollment is conducted in a timely and accurate manner to ensure all regulations and provider contract requirements are met. Serve as the LPCH administrative point of contact for the LPCH Medical Executive Committee and Credentials Committee.

Decision Making: Independent judgment in making decisions from many diversified alternatives that are subject to general review in final stages only.

Working Relationship: Direct Supervision of others - No. of people supervised: 3 Prepares and gives performance evaluations. Works directly with patients and/or customers. Works with internal/external customers. Works with other healthcare professionals and staff. Works frequently with individuals at manager level or above.

Special Job Dimensions: None.

Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job.  This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.

Quality Improvement - Laureate Campus

Location:

Tulsa, Oklahoma 74136