Quality Assurance Director

City of Alexandria•Alexandria, VA

1d•Onsite

About The Position

The Quality Assurance Director leads and directs all activities and management of the quality assurance and improvement for the Alexandria Community Services Board (ACSB) and serves as an advisor to the department on quality assurance standards, risk mitigation, and compliance matters. This position qualifies for a signing bonus of $3,000.

Requirements

Three years of program management experience in a community mental health or similar setting
Three years of experience providing mental health and/or substance abuse services, including diagnostic evaluations, crisis intervention, and case management
Possession of an M.S.W., M.A., M.S. N. or a PH.D. degree from an accredited school
Virginia Licensure or immediate eligibility for Virginia licensure at the time of appointment as a LCSW, LPC, Clinical Nurse Specialist, or Clinical Psychologist
Any equivalent combination of experience and training which provides the required knowledge, skills and abilities.
Vast experience and comprehensive knowledge of the principles and practices of Quality Assurance/Quality Improvement, data analysis
Demonstrated knowledge of community and human services as well as human centered principles and practices of delivery systems.
Ability to obtain data from credible sources and incorporate such information into effective program and planning activities
Experience in establishing and maintaining working relationships with City officials, employees, and licensing and accrediting bodies.
Ability to write clear and concise reports and speak effectively on a range of community and human service program areas.
Ability to organize and prioritize work, be proactive, take initiative, resolve problems, follow through, work with diverse teams, and simultaneously manage multiple projects, ensure that goals are met in a timely manner and handle confidential information with integrity
Willingness to learn about the legacy data systems of the City and department’s state and federal funding sources.
Hands-on experience and demonstrated proficiency in working with Microsoft Office (Outlook, Word, PowerPoint, and Excel) Suite
Basic knowledge of data analysis tools, survey software and SharePoint environment.
Successful completion of pre-employment background checks including but not limited to: FBI/Federal Records Check; VA State Child Abuse/Neglect Registry; Medicare/Medicaid Fraud Database; education/certifications; and driver’s license.

Nice To Haves

Five years of experience leading organizations in the management of quality assurance and improvement systems.
Five years of post-licensure with clinical and administrative experience working with individuals with a developmental disability and/or mental health and/or co-occurring substance use disorder
Experience and ability to effectively use an electronic clinical record and data systems and to train and assist clinical staff and supervisees with same.
Knowledge of Virginia regulations related to the activities of the department
Knowledge of the system of care in the City of Alexandria.

Responsibilities

Provide expert guidance to management and clinical staff on quality assurance and documentation standards by ensuring clinical excellence across the lifespan of our consumers and behavioral health spectrum of care to include, intellectual/developmental disabilities, and substance use services by maintaining rigorous standards for documentation, compliance, and evidence-based practice.
Ensures maintenance of CSB licenses and accreditation of the department.
Provides significant input and aligns the electronic health record platform to ensure seamless information management and clinical compliance for diverse patient populations.
Act as the primary Corporate Compliance Officer and Human Rights Advocate, conducting audits to meet state and federal mandates.
Administer collection of information about clinical program operations by conducting and coordinating Quality Assurance audits to determine the extent to which statutory, professional, department, licensing and funding requirements are met.
Manage and maintain critical incident data for reporting purposes and quality assurance and improvement.
Formulate and implement organizational changes by researching "best practices" in behavioral health and revising department policies.
Direct the activities of the Quality Assurance, Health Information, and HIPAA Privacy Officer.
Serves as a Chair for the following committees: multi-disciplinary Quality Assurance Committee, Safety Committee, Ad Hoc Corporate Compliance and Research Review Committee.
Serves as a Co-Chair for the following committees: Policy and Procedure Committee, Root Cause Analysis Committee(s), CAP Follow Up Committee.
Training development and didactic training to clinical staff in the documentation of clinical practices in the electronic health record.
Makes recommendations regarding improving clinical practices and procedures to Alexandria Community Services Board Leadership Team to ensure best practice, regulatory and accredited compliance.
Serves as Risk Manager for the CSB; oversees the CSB’s risk management activities, including maintaining and updating the Risk Management Plan.
Strengthens organizational compliance by developing, recommending, and implementing accreditation-aligned policies and procedures for leadership approval as well as the preparation of procedures and/or reports for review and clearance by ACSB Leadership Team.
Maintains and exercises technical expertise in interpretation and application of statutory requirements such as those pertaining to eligibility for multiple local, State and federal financial assistance programs, licensing and/or accreditation standards.
Ensures operation of all State licensed facilities and programs in accordance with State licensing requirements such as those for medical records, maintenance, personnel procedures and records, program reviews and medication procedures.
Ensures agency-wide compliance with federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Works in concert with Health Information Management (HIM) on conversions necessary for compliance with the Affordable Health Care Act.
Ensures completion and documentation of safety drills per licensing and accreditation requirements; monitors the agency’s incident reporting database and reports trends and recommendations to senior management.
Serves as Human Rights Advocate for State licensed programs as required by the Code of Virginia, coordinates human rights investigations and reports to State agencies and senior management as required.
Responsible for the coordination of CSB’s accreditation and re-accreditation processes.
In collaboration with IT, Reimbursement, and Program Evaluation Departments, coordinates implementation of EHR changes and/or updates as they relate to clinician use of the data system.
Serves as DCHS Corporate Compliance Officer; provides oversight for corporate compliance activities to include complaints related to ethical, legal or compliance practices.
Establishes goals and objectives, prepares program reports, and evaluates the effectiveness of all QA programs with CSB Leadership Team and clinical staff.
Monitors program compliance with all required licenses and certifications.
Assures program quality is maintained by coordinating peer review activities and analyzing external reviews.
Ensures maintenance of CSB licenses with the State Department of Behavioral Health and Developmental Services.
Develops, implements and maintains record audits, including maintaining data collection data base and providing summary reporting to appropriate clinical and leadership staff.
Represents the Department on Statewide and regional Quality Assurance committee(s).
Perform other duties as assigned by the Deputy Director.