Quality Improvement Specialist- Cayuga Addiction Recovery Services Men's Residence- Full Time- Days

Cayuga Health System • Town of Ulysses, NY

24d • $80,000 - $100,000 • Hybrid

About The Position

The Quality Improvement Specialist (QIS) for Substance Use Disorder and Behavioral Health will serve the Cayuga Addiction Recovery Service programs by providing operational and tactical leadership in advancing the quality, safety, and compliance of programs and entities governed and credentialed by the New York State Office of Mental Health (OMH), Office of Addiction Services and Supports (OASAS), Substance Abuse and Mental Health Services Administration (SAMHSA), Drug Enforcement Agency (DEA) and Commission on Accreditation of Rehabilitation Facilities (CARF). Reporting to the Sr. Director of Operations, this position executes the organization's quality and performance improvement initiatives within behavioral health and substance use disorder entities, including Cayuga Addiction and Recovery Services for the Ithaca, Cortland, and Trumansburg Programs. The QIS partners with clinical, operational, and data leaders to ensure program fidelity, regulatory readiness, and continuous improvement in patient outcomes and experience (perception of care for CARS). The QIS reports to the Sr. Director of Operations of Cayuga Addiction Recovery Services, ensuring that priorities are adequately aligned both operationally and strategically. The QIS will be responsible for Perception of Care Surveys, Client Experience, Utilization Review, and the execution of the Quality Assurance and Performance Improvement Plan approved annually. The role plays a critical part in aligning behavioral health and substance use disorder activities under Centralus Health's broader quality strategy, integrating regulatory compliance, value-based measures, and population health priorities across the continuum of care.

Requirements

• Bachelor's degree in healthcare, social work, psychology, public health, or a related behavioral health field.
• Certified Professional in Healthcare Quality (CPHQ) required within two years of hire.
• Minimum 3-5 years of experience in substance use disorder/behavioral health quality improvement, regulatory compliance, or performance analytics.
• Demonstrated understanding of OMH, OASAS, and SAMHSA program standards and reporting requirements.
• Experience in data analysis, performance tracking, and process improvement methodologies such as Lean, Six Sigma, or QI Model for Improvement.
• Proficiency in EHR systems, data visualization tools (e.g., EPIC, Vizient, PHP), and project documentation.

Nice To Haves

• Clinical or behavioral health licensure (e.g., LCSW, LMHC, CASAC, or RN).
• Experience with Substance Use Disorder, Behavioral Health, and Addiction Medicine programs.
• Experience supporting program accreditation or certification (e.g., CCBHC, CARF, and Joint Commission Behavioral Health).
• Knowledge of value-based behavioral health metrics, population health integration, and trauma-informed care frameworks.
• Lean Six Sigma Green Belt or equivalent improvement certification.

Responsibilities

• Implement and evaluate quality improvement initiatives across OMH-, OASAS-, and SAMHSA-governed programs to enhance clinical outcomes, patient experience, and compliance with agency standards and evidence-based practice models.
• Responsible for providing all regulatory required reports to the Board of Directors in accordance with regulation.
• Responsible for developing and implementing quality management plans, conducting audits, OASAS mock audits and reviews, evaluating performance data ,and leading corrective action processes to enhance client care and outcomes.
• Ensure continuous readiness for OMH, OASAS, and SAMHSA site reviews, audits, and certification surveys by maintaining program documentation, tracking corrective actions, and ensuring fidelity to federal and state behavioral health/substance use disorder regulations.
• Partner with the Quality Department to collect, validate, and analyze behavioral health/ substance use disorder performance metrics, including incident trends, access, continuity of care, engagement, and readmission data. Use data visualization and analytics tools to translate findings into actionable improvement plans.
• Collaborate with CARS leadership to monitor adherence to program-specific requirements such as CQI standards, OASAS Part 822 & 820, and SAMHSA evidence-based model fidelity
• Assist in developing and maintaining policies, workflows, and documentation tools that reflect current OMH/OASAS/SAMHSA standards, ensuring consistent implementation and audit readiness.
• Translate quality goals into structured project plans; track milestones, measure outcomes, and adapt based on emerging performance data or regulatory updates.
• Create and maintain dashboards and reports that display behavioral health outcomes, regulatory compliance status, and improvement progress. Present findings to CARS Program Leadership and Sr. Director of Operations
• Apply Lean, Six Sigma, and QI methodologies to behavioral health improvement projects. Support team development and organizational learning through sharing best practices and facilitating staff education.
• Other duties as assigned.
• Demonstrated execution of quality improvement projects
• Support patient safety initiatives
• Use verbal and written communication skills to establish and maintain effective relationships, facilitate multi-disciplinary teams, and produce written and/or verbal reports

Benefits

• Centralus Health and its affiliates are committed to treating all patients, providers, staff and volunteers equitably and with dignity, ensuring the highest levels of safety, care and respect, and striving to recognize and overcome biases and policies that contribute to disparities in healthcare access, equitable care and positive health outcomes for all.
• We are proud to be an Equal Employment Opportunity employer, supporting the growth and health of our employees and community by embracing the rich diversity, needs and circumstances of all peoples and prioritizing opportunities to build a diverse and inclusive workplace. We do not discriminate upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable protected characteristics.
• If you require reasonable accommodation to complete a job application, pre-employment testing, a job interview or to otherwise participate in the hiring process, please contact the Centralus Health Talent Acquisition team at [email protected].

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level