Quality Assurance Director-Manager III

Texas Health & Human Services Commission•San Antonio, TX

13d•$5,425 - $8,886•Onsite

About The Position

The Quality Assurance Director performs complex supervisory and consultative work involving the planning, development, implementation, and monitoring of quality assurance systems at San Antonio State Hospital. The position ensures the facility complies with Centers for Medicare and Medicaid Services (CMS) conditions of participation, The Joint Commission (TJC) standards, and applicable state and federal laws, rules, and regulations. The director interprets standards, develops and disseminates policy, provides consultative support to program staff, and coordinates quality-enhancement activities and reporting. The role evaluates service delivery and compliance, analyzes program operations and data for trends and improvement opportunities, verifies data accuracy, recommends changes, and develops training as needed. It also oversees plans of correction, responds to crises, and prepares reports. The director leads the Quality Assurance/Quality Management team and client records department staff, hiring, developing, assigning, and supervising employees. The role serves on or chairs committees and work groups, including the Quality Improvement Council (QIC), and collaborates with the Superintendent and department leads. It acts as the facility liaison with HHSC Regulatory, CMS, and TJC before, during, and after monitoring visits. The position works under the general supervision of the State Hospital Superintendent, with moderate latitude for initiative and independent judgment. It serves in an on-call rotation, including after-hours and weekends, and may serve as Executive or Administrator on Duty. Disaster-response or Continuity of Operations duties may require an alternate shift or location.

Requirements

Bachelor’s degree from an accredited college or university and three years of work experience in service delivery systems for persons with mental health diagnoses and/or quality assurance; OR seven years of work experience in service delivery systems for persons with mental health diagnoses, including at least two years of quality-assurance duties.
Knowledge of CMS conditions of participation, TJC standards, interpretive guidelines, and survey processes.
Knowledge of Texas Administrative Code and HHSC policies and procedures related to State Hospitals.
Knowledge and experience in ensuring quality services, treatment, training, and supports for patients with mental health diagnoses.
Knowledge of developing and implementing plans of correction and quality-improvement programs.
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, writing quality-improvement plans, and developing tracking systems.
Task-management, teamwork, delegation, and leadership skills, including prioritizing others’ work.
Ability to develop written policies and guidelines to ensure compliance with applicable standards.
Ability to manage department business functions and activities and to plan, assign, and supervise work.
Ability to gather, assemble, and correlate data for trend analysis.
Ability to facilitate work groups and meetings and present information effectively in spoken and written form to varied audiences.
Ability to analyze and solve complex problems and make effective decisions affecting facility operations.
Ability to manage time and exercise independent judgment.
Ability to maintain flexibility in work hours, including overtime or extended hours.
Effective oral and written communication and attention to detail.
Ability to articulate a vision for quality improvement and develop concrete implementation plans.
Pass required fingerprint criminal background, pre-employment drug, and registry checks; applicable checks include CANRS, Nurse Aid, Medication Aide and Employee Misconduct, and LEIE.
Applicants must be at least 18 years old for employment at a state-operated facility.
Comply with HHSC immunization policy and state hospital immunization-related operating procedures.
Serve in an on-call rotation and be available for after-hours and weekend facility issues.

Responsibilities

Plan, develop, implement, and monitor facility quality assurance systems and quality-enhancement efforts.
Ensure compliance with CMS conditions of participation, TJC standards, HHSC policies and procedures, and applicable state and federal requirements.
Interpret standards and regulations, develop and disseminate policy, and provide technical or consultative guidance to program staff.
Analyze and evaluate program operations, service delivery, procedures, systems, and data; verify data accuracy; identify trends and systemic issues; and recommend improvements.
Develop, schedule, and prioritize processes for achieving goals; proactively identify problems and provide solutions.
Develop and provide in-service and training modules, ensure staff training on policy changes, and maintain training documentation.
Oversee the Quality Assurance/Quality Management team and client records department staff, including hiring, training, performance evaluations, staff development, and retention efforts.
Plan, assign, and supervise daily staff activities, including the work of program auditors, data analysts, records coordinators, clinical safety coordinators, nurse auditors, and administrative staff.
Direct quality-assurance data collection, monitoring, analysis, and reporting; maintain monitoring systems and databases and support data integrity.
Oversee the Quality Improvement Council process, including agendas, presentations, reports, meetings, and recurring review of facility data.
Attend Morning Report and participate in the Executive Team, QIC, Medical Executive Committee, and other work groups as needed.
Act as liaison between the facility and HHSC Regulatory, CMS, and TJC before, during, and after monitoring visits; coordinate surveyor communications and documentation and respond to concerns.
Oversee development, submission, monitoring, and evidence collection for plans of correction addressing deficiencies cited by HHSC Regulatory, CMS, or TJC.
Coordinate internal monitoring, assign monitoring work, meet with department leads, and maintain systems for review by the QIC.
Oversee implementation and documentation of HHSC and facility policies, develop localized procedures, and prepare required reports.
Serve in the on-call rotation and as Executive or Administrator on Duty as needed, 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, recovery, or Continuity of Operations activities as assigned, potentially at an alternate shift or location.
Perform other duties as assigned.