Quality & Licensing Manager

Fora Health•Portland, OR

3d•Hybrid

About The Position

The Quality Management (QM) improves efficiency and effectiveness, utilizing current external and internal regulatory standards to bring excellence in care. By monitoring, identifying, reporting and documenting results of department-led quality efforts, continuous improvement is reviewed and achieved. The QM team anticipates potential problems due to early identification of concerning trends and collaborates with department leaders to develop proactive interventions. The Quality & Licensing Manager is a leadership position serving a key role in facilitating activities related to quality of care, licensing and accreditation, service delivery and contracting within all Fora Health locations. The position collaborates closely with Quality Management staff, the Executive Team, operational leaders, and other staff to create and support a service environment that empowers patients to recover. The position serves as a highly visible, energetic champion of quality and patient care; focuses on pro-active identification of risks and opportunities to continually improve the safety, effectiveness, efficiency, patient-centeredness, equity and timeliness of behavioral and medical health care services to patients. Quality & Licensing Manager oversees the licensing and accreditation process in a manner which secures continuous certification of program services and endorsement from Commission on Accreditation of Rehabilitation Facilities (CARF), and leads the development of appropriate metrics for success. patient ESSENTIAL JOB FUNCTIONS Provides direct administrative supervision and oversight to the Quality Specialist team. Works to ensure the utilization of clinical data to support the identification of quality issues and improvement opportunities, drive prioritization and decision making and monitor improvement activities. Such data may include: Patient Satisfaction surveys Referent Satisfaction surveys Climate survey (staff satisfaction) Other consumer satisfaction surveys Engagement/retention outcomes data Unusual Incident Reports Patient Grievance Develops annual quality improvement plan in collaboration with the Director of Operations & Compliance and in accordance with the organization’s strategic plans, CARF, and the Oregon Administrative Rules standards. Monitors and tracks achievements of quality metrics. Presents quarterly updates to the Executive Team. Oversees patients’ rights and grievance procedure. Oversees incident reports and serves as a member of Health & Safety Committee. Responsible for the work product; chairs the Quality Management Committee and any of its sub-committees and ensures quality management team members are actively engaged Leads data collection, analysis and reporting for established quality/patient safety practices. Creates, modifies, or edits policy and procedures in collaboration with the Director of Operations & Compliance. Plans and advocates for the implementation of Continuous Quality Improvement principles in the operation of the organization. In collaboration with the Chief Clinical Officer, develops quality indicators and other meaningful outcome measures; develops procedures for related data collection through planned program reviews and reporting based on state/county requirements, contract requirements and CARF standards if applicable. Collaborates with appropriate staff to ensure that identified opportunities for enhancement are implemented, monitored, completed and evaluated. Collects data to evaluate the quality of support and services, including the areas of patient records, utilization management, and medication services. Reports pertinent information to appropriate individual(s) and/or committee(s). Recommends areas for development and, when appropriate, evaluates the results of those areas with the Chief Executive Officer. Conducts Quality of Care reviews in each clinical department to assure that all departments are delivering services according to P&P, philosophy, treatment model and practices as well as the values of the organization. Annually and ongoing as needed, evaluates the operation of Fora Health's Quality Management Program as it relates to policies and procedures, new implementations and state regulations in collaboration with the Director of Operations & Compliance and the Executive Team. Develop Annual QI Report focusing on improvement of “high risk, high volume, high cost” areas of concern. As requested/needed, communicates Quality Management activities and findings to the CEO and Board of Directors. Will be required to travel to multiple locations and participate in community-based quality management meetings. Perform other related duties as required or assigned. Oversee licensing and accreditation process in a manner which secures continuous certification of program services and endorsement from Commission on Accreditation of Rehabilitation Facilities (CARF). Acts as point of contact and liaison for licenses, accreditations, and panels. Prepares for and hosts site reviews, ensuring agency receives positive results and minimal findings. Assures that CARF, State and County MH and Addiction Services corrective action plans are completed, implemented and that regulatory agencies are notified within prescribed time frames. SUPERVISORY FUNCTIONS Provides administrative supervision and oversight to the Quality Specialist team.

Requirements

Minimum four (4) years of experience working with multi-disciplinary work groups, including clinical staff, focused on service delivery and/or quality improvement activities in a hospital or health care organization.
At least two years of this experience must include responsibilities as a leader of a team, work group or program.
3 years supervisory or management experience required.
Possession of a Bachelor’s Degree from an accredited college or university, preferably in a health or human service field such as hospital administration, public health, allied health or related area.
Possession of a Master's Degree from an accredited college or university, preferably in a health or human service field, may be substituted for two years of experience.
Experience gathering, organizing, analyzing, and interpreting aggregate data and using the data to identify problems and make recommendations.
Experience authoring written documents or reports in areas related to service delivery and/or quality assurance activities.
Process improvement skills.
Strong knowledge and understanding of the concepts of Continuous Quality Improvement (e.g., Six Sigma; Lean) and related regulatory requirements.
Strong analytical and problem-solving skills; knowledge of regulatory and licensure standards, risk management and safety desirable.
Project management experience with process measurement, clinical data collection, process change and working knowledge of regulatory and value-based performance requirements strongly preferred.
Ability to facilitate training sessions.
Knowledge, experience and proficiency with personal computer software including word processing, spreadsheets, statistical analysis, graphics and Outlook.
Valid driver’s license, current auto insurance and clean driving record for past 3 years
Ability to listen, problem-solve and develop strong interpersonal relationships with others; Ability to develop effective, team-oriented working relationships with staff who have diverse responsibilities and functions.
Ability to prioritize and manage multiple projects simultaneously with demonstrated ability to complete projects successfully on time and to the satisfaction of key stakeholders.
Aptitude for detail oriented work with a high level of accuracy.
Excellent leadership attributes including positive, can-do attitude, creativity and enthusiasm.
Strong verbal presentation skills
Highly developed skills using personal computer tools including word processing, spreadsheet and presentation applications.
Knowledge of risk management, infection prevention, and other patient safety and risk topics.
Knowledge of performance improvement principles, theories and practices.
For employees with a history of substance use disorder, Fora Health’s policy requires certification of a minimum of six months of sobriety for this position.
Ability to pass a pre-employment or for cause drug tests.
Position will require some amount of regular connection to work via cell phone to answer questions and respond to internal and external contacts.

Nice To Haves

Project management experience with process measurement, clinical data collection, process change and working knowledge of regulatory and value-based performance requirements strongly preferred.
Experience is preferred.
Knowledge of regulatory and licensure standards, risk management and safety desirable.

Responsibilities

Provides direct administrative supervision and oversight to the Quality Specialist team.
Works to ensure the utilization of clinical data to support the identification of quality issues and improvement opportunities, drive prioritization and decision making and monitor improvement activities.
Develops annual quality improvement plan in collaboration with the Director of Operations & Compliance and in accordance with the organization’s strategic plans, CARF, and the Oregon Administrative Rules standards.
Monitors and tracks achievements of quality metrics.
Presents quarterly updates to the Executive Team.
Oversees patients’ rights and grievance procedure.
Oversees incident reports and serves as a member of Health & Safety Committee.
Responsible for the work product; chairs the Quality Management Committee and any of its sub-committees and ensures quality management team members are actively engaged
Leads data collection, analysis and reporting for established quality/patient safety practices.
Creates, modifies, or edits policy and procedures in collaboration with the Director of Operations & Compliance.
Plans and advocates for the implementation of Continuous Quality Improvement principles in the operation of the organization.
In collaboration with the Chief Clinical Officer, develops quality indicators and other meaningful outcome measures; develops procedures for related data collection through planned program reviews and reporting based on state/county requirements, contract requirements and CARF standards if applicable.
Collaborates with appropriate staff to ensure that identified opportunities for enhancement are implemented, monitored, completed and evaluated.
Collects data to evaluate the quality of support and services, including the areas of patient records, utilization management, and medication services.
Reports pertinent information to appropriate individual(s) and/or committee(s).
Recommends areas for development and, when appropriate, evaluates the results of those areas with the Chief Executive Officer.
Conducts Quality of Care reviews in each clinical department to assure that all departments are delivering services according to P&P, philosophy, treatment model and practices as well as the values of the organization.
Annually and ongoing as needed, evaluates the operation of Fora Health's Quality Management Program as it relates to policies and procedures, new implementations and state regulations in collaboration with the Director of Operations & Compliance and the Executive Team.
Develop Annual QI Report focusing on improvement of “high risk, high volume, high cost” areas of concern.
As requested/needed, communicates Quality Management activities and findings to the CEO and Board of Directors.
Will be required to travel to multiple locations and participate in community-based quality management meetings.
Perform other related duties as required or assigned.
Oversee licensing and accreditation process in a manner which secures continuous certification of program services and endorsement from Commission on Accreditation of Rehabilitation Facilities (CARF).
Acts as point of contact and liaison for licenses, accreditations, and panels.
Prepares for and hosts site reviews, ensuring agency receives positive results and minimal findings.
Assures that CARF, State and County MH and Addiction Services corrective action plans are completed, implemented and that regulatory agencies are notified within prescribed time frames.
Provides administrative supervision and oversight to the Quality Specialist team.