This role will oversee the Hospital’s efforts to comply with accreditation, regulatory and payor requirements. The Director will manage the preparation for and coordination of surveys, audits and reviews. This role will act as a change agent for process improvement initiatives including assessment, design, implementation and outcome measures.
- Oversee activities related to compliance with the requirements of Federal and State regulatory agencies, payors, and accreditation organizations. This individual will interact with internal and external groups to support these activities.
- Continually monitor licensing, accrediting and other standards and provide updates and recommendations on any changes to the appropriate business/functional areas.
- Educate staff on licensing, regulatory and accreditation requirements and provide consultation and technical assistance as needed to improve compliance with these requirements.
- Oversee surveys/site visits with licensing, accrediting and other agencies - including coordination of internal survey preparation, on-site assistance to surveyors, and the development and implementation of a corrective action plan for any deficiencies noted.
- Respond to quality incidents, issues, and complaints
- Collaborate with staff to develop and lead quality initiatives
- Master’s degree from an accredited college with a major in business or health administration or other related field required. Nursing, Social Work or Psychology degree is a plus.
- Certified Professional in Healthcare Quality or Certified Professional in Healthcare Risk Management in a behavioral health setting preferred.
- A thorough knowledge of regulatory and accreditation requirements (JCAHO, CMS, DOH, DDAP, OMHSAS).
- Experience in behavioral health with a minimum of two years as a leader or manager.
- Knowledge of current and emerging quality improvement practices, data analytics and system redesign.