Manager III

Texas Health & Human Services Commission•Vernon, TX

1d•$5,425 - $8,886•Onsite

About The Position

The Quality Assurance Director performs complex supervisory and consultative work in planning, developing, implementing, and monitoring quality assurance systems at Vernon State Hospital. The role ensures the facility complies with CMS conditions of participation, The Joint Commission standards, and applicable state and federal laws, rules, and regulations. It interprets standards, develops and disseminates policy, advises program staff, and coordinates quality enhancement and reporting activities. The position evaluates service delivery and operational systems, analyzes data for trends and improvement opportunities, identifies problems and solutions, implements directives, responds to emergencies, and oversees plans of correction. It also develops and coordinates training and reports, supervises the Quality Assurance/Quality Management team, and serves as a liaison among the facility, HHSC Regulatory, CMS, and The Joint Commission. The position works under the general supervision of the State Hospital Superintendent, with moderate latitude for initiative and independent judgment. It collaborates with the Superintendent and department leads, serves on or chairs committees and work groups, and participates in an on-call rotation for facility issues after hours and on weekends. The role may also support disaster response, recovery, or Continuity of Operations activities, potentially requiring a different shift or work location.

Requirements

Bachelor’s degree from an accredited college or university and three years of work experience in service delivery systems for people with mental health diagnoses and/or quality assurance; or seven years of work experience in service delivery systems for people with mental health diagnoses, including at least two years in duties related to quality assurance.
Experience with standards, applicable rules, and laws related to CMS conditions of participation, The Joint Commission standards, or other acute or hospital settings.
Knowledge of CMS conditions of participation, The Joint Commission standards, interpretive guidelines, and survey processes.
Knowledge of the Texas Administrative Code and HHSC policies and procedures related to State Hospitals.
Knowledge and experience in ensuring quality services, treatment, training, and support for patients with mental health diagnoses.
Skills in defining problems, collecting data, establishing facts, and conducting root cause analysis.
Skill in using logic and reasoning to assess alternative solutions and approaches to problems.
Computer skills, including Microsoft Word, Excel, PowerPoint, Access, Outlook, SharePoint, and agency or facility software.
Skills in motivating staff, facilitating change, and writing quality improvement plans.
Ability to develop written policies and guidelines to support facility compliance with applicable standards.
Ability to manage department business functions; gather, assemble, and correlate data for trend analysis; and facilitate work groups and meetings.
Ability to present information effectively, orally and in writing, to varied audiences; analyze and solve complex problems; make decisions affecting facility operations; and plan, assign, and supervise work.
Ability to manage time with independent judgment and maintain flexibility in work hours, including overtime or extended hours.
Must pass required fingerprint criminal background, pre-employment drug, and registry checks.
Must be at least 18 years old to work at a state-operated facility.
Must comply with HHSC immunization policy and state hospital operating procedures related to immunizations.

Nice To Haves

Experience ensuring quality services for persons with mental health diagnoses.
Experience leading and/or supervising employees.

Responsibilities

Lead, plan, assign, and supervise the daily activities of quality assurance department and client records department staff, including hiring, training, performance evaluation, and staff development.
Direct quality assurance functions, including support for data collection, monitoring, analysis, and reporting, and use information to identify performance issues and inform decisions.
Identify potential and actual problems, report them to appropriate supervisors or managers, and provide feedback to department leads and discipline coordinators for process improvement.
Oversee the Quality Improvement Council process, including agendas, presentation schedules and content, reports, and meeting facilitation when requested.
Attend Morning Report meetings and serve on the Executive Team, Quality Improvement Council, and Medical Executive Committee, as well as other work groups.
Act as liaison between the facility, HHSC Regulatory, CMS, and The Joint Commission before, during, and after monitoring visits; coordinate surveyor access and documentation and respond to concerns.
Oversee staff auditors and data analysts, databases, facility-wide monitoring systems, statistical analysis, and collaboration to validate and improve data integrity.
Oversee development and submission of plans of correction, ensure they address deficiencies with measurable outcomes and meet due dates, and organize supporting evidence for surveyors.
Conduct meetings with department leads, coordinate monitoring samples and assignments, and maintain systems and schedules for monitoring reviewed by the Quality Improvement Council.
Oversee analysis, implementation, and documentation of HHSC and hospital policies; develop local policies and procedures and ensure staff training and documentation are completed.
Develop and provide in-service and training modules, prepare required reports, and ensure staff are trained on policy changes.
Serve in the Executive or Administrator on Duty capacity in rotation and be on call as needed, including responding to facility issues after hours and on weekends.
Respond to crisis or emergency situations and take immediate action to resolve issues.
Participate in disaster response or recovery and Continuity of Operations activities as assigned.