PRIMARY OBJECTIVE:

To ensure the overall implementation of quality of programs and services are provided in accordance with all federal, state and corporate standards and regulations. Provides the leadership needed to ensure services provided meet the goals of the individuals served and the mission, and philosophy of the agency. Plays an integral role in the facility’s pursuit of accreditation from a nationally recognized accreditation body.

KNOWLEDGE, SKILLS, AND ABILITIES NEEDED TO PERFORM JOB:

• Bachelor’s degree in the human service discipline, healthcare administration, or related field
• 1 year of experience working in the ID/DD field preferred
• 2 years of leadership experience required
• Proven experience in conducting investigations, implementing corrective actions, and overseeing quality initiatives.
• Experience working with national accreditation bodies (e.g., CQL, CARF) is highly desirable.
• Familiarity with the regulatory standards for ICFs and experience navigating state and federal compliance requirements (DIDD, CMS) is highly desirable.
• Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint) and electronic health record (EHR) or quality management software.

DISCLAIMER:

The above information on this description has been designed to indicate the general nature and level of the work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
The company reserves the right to revise or change job duties as business requirements dictate. It is mutually agreed that this job description does not constitute a written or implied contract of employment. It is understood that the company reserves the right to change work schedules as required, including overtime

• Coordinate quality assurance activities across multiple operations to ensure consistent adherence to high-quality standards and compliance with state and federal regulations.
• Monitor, analyze and provide monthly reporting on key quality performance indicators (KPIs) for all departments, ensuring operational excellence and alignment with the company’s quality goals.
• Collaborate with department managers to assess quality indicators and identify areas for improvement across various operations.
• Perform root cause analyses (RCA) for identified incidents, ensuring that Plans of Correction (POC) are developed, tracked, and executed effectively.
• Review Incident Management notes, follow up, and documentation to ensure compliance
• Participate in the facility’s efforts to seek accreditation from a nationally recognized accreditation body
• Assist in preparing for accreditation surveys, ensuring all required documentation, policies, and procedures are up to date and compliant with accreditation standards.
• Participate in the development and execution of action plans to address any areas for improvement identified during the accreditation process
• Complete audits to ensure accurate and timely documentation of all quality-related activities, including investigations, corrective actions, audit results, and accreditation preparation.
• Prepare and present reports on quality performance and accreditation status to senior leadership and relevant stakeholders.
• Facilitate internal Commitment to Excellence process for responsible areas.
• Collaborate with Quality Services Director(s) (QSD) to provide oversight, training, and support for quality management initiatives, traveling to the city as needed
• Assist with the coordination of accreditation assessments, audits, and other quality-related events that may require travel to operations in responsible areas or conferences.
• Perform QSD role on an interim basis if the position is vacant
• Other duties as assigned.