Job Summary:

The Director of Quality & Accreditation maintains overall responsibility of quality initiatives to include but not limited to the assurance, continuous improvement, measured outcomes, performance plans, and policy advisement. Ensures the organization is consistently providing best practice standards and maintains compliant regulatory accreditation standing for every operating site. Responsible for promoting, coordinating, and/or performing quality improvement monitoring and evaluating of programs and staff. Trains staff in total quality improvement performance. Provides consultation to programs and supervises staff efforts to meet established quality improvement criteria.

Essential Functions:

1. Quality Improvement and Assurance (60%)

a. Leads quality assurance strategies and planning; oversee implementation and effectiveness.

b. Participates in the development and oversight of cross-functional initiatives with accountability for components related to quality of care, grievance system, and program integrity.

c. Develops, updates and revises policies and procedures related to areas of accountability and outcome measurements.

d. Oversee performance management team. Drive outcomes through data drive measurements,

e. Provides oversight and directs staff in implementing processes for delegation and quality oversight including care and utilization management, quality assurance, performance improvement, and program integrity.

f. Develop and lead a Quality & Process Improvement Committee, including representation from all aspects of BCTS clinical services and support, to create and maintain a culture of implementing, measuring/evaluating, and identifying opportunities for improvement in processes involving quality, integrity, data management, and efficiency in BCTS’ quality processes.

g. Conduct prompt and confidential investigations for any quality or compliance incidents that may occur with appropriate documentation and corrective actions, if needed.

h. Serve as the lead/point person to prepare or respond to any clinical audits or site inspections.

2. Accreditation (20%)

a. Ensure clinical license and accreditation support throughout the agency. Complete corrective action plans and implement strategies to ensure state licensing and regulatory compliance.

b. Support site leadership in the OHA licensing of each facility.

c. Oversee CARF standards and principles agency wide. Assist with policy development to align accordingly.

d. Supervise CARF accreditation staff who provide internal team-based support in the application of standards in the day-to-day operations of the organization.

3. Management (20%)

a. Recruits, hires, and supervises the department staff, including ongoing coaching, development and performance management.

b. Demonstrates and supports the organizational mission and goals of BCTS including its commitment to diversity, equity and inclusion, compassion and superior customer service.

Qualifications:

Education/Licensure/Certification:

• Master’s degree or equivalent experience in behavioral health field, nursing, health service administration, public health, or related field preferred (MSN, MHA, MHQS, MBA)
• Bachelor’s Degree from an accredited institution, or advanced medical degree and/or licensure required
• Current state license in area of clinical training (LPC, LCSW, RN)
• CPHQ Certification or will obtain within 12 months of employment (Certified Professional in Healthcare Quality) or CHC Certification (Certified in Healthcare Compliance)

Experience:

• Preferred experience in a CARF accredited organization
• Proficiency in navigating electronic health record system preferred
• Minimum of 5 years of experience working directly with corporate compliance programs in a healthcare setting

· Minimum 5 years of successful managerial or supervisory leadership in healthcare quality management

· Working knowledge of and expertise with CARF, HIPAA, Medicare and Medicaid, and other State and Federal regulations and statutes relating to addiction treatment services.

· Extensive knowledge and experience with industry-leading quality improvement methods and tools

Knowledge, Skills and Abilities:

· Proficiency in use of Microsoft applications (e.g. Office 365, Excel, Word, One-Note, Teams, PowerPoint), and virtual meeting and training facilitation

· Proficiency with electronic health record systems

· Knowledge of statistical tools and process improvement methodologies

· Proficiency in data validation processes

· Exceptional interpersonal, verbal, and written communication skills. Must be able to present data, plans, ideas, and information in an effective, organized and compelling manner in a variety of settings to diverse audiences

· Ability to define problems, collect data, establish facts, analyze, and draw valid conclusions

· Professional and tactful interpersonal skills with the ability to interact with staff and leadership of all levels

· Ability to maintain confidentiality, think and act independently with minimal supervision, and a high level of integrity, confidentiality, and reliability

· Strong leadership and supervisory skills

· Excellent organizational skills and attention to detail

· Excellent time management skills with proven ability to meet deadlines

· Ability to cultivate relationships, rapport, credibility and partnerships across all levels of internal and external customers

· Ability to be flexible, approachable and inspire trust

· Exercises good judgment, demonstrates effective critical-thinking skills

Tools and Equipment Used:

Computer/laptop and software applications, printers, fax machine, copy machine, telephone.

Physical Demands:

The physical demands described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing this job, the employee is regularly required to reach with hands and arms. The employee is frequently required to stand, walk, sit, and use hands to handle, feel or operate objects or controls. The employee is occasionally required to climb or balance; stoop, kneel, crouch, or crawl; and must be able to talk and hear. The employee must occasionally lift and/or move up to twenty (20) pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Must wear protective clothing and Personal Protective Equipment (PPE) as required. Able to travel to various locations on occasion.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The position requires the employee to dress in a professional manner that meets the standards for professional attire in Central Oregon.

Job Type: Full-time

Pay: $80,000.00 - $120,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Redmond, OR 97756: Reliably commute or planning to relocate before starting work (Required)

Work Location: One location

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