ESSENTIAL FUNCTIONS:

Provide oversight of quality data collection, monitoring, analysis and reporting. Monitor and analyze QM data for review by facility management. Submit data to external agencies as required. Assist in annual preparation and evaluation of the facility Quality plan. Complete QM projects and incorporates the results into patient care improvements. Manage facility compliance with policies and applicable standards as required by regulatory/accrediting bodies. Submit monthly scorecard data to Acadia corporate office. Assist in investigation and root cause analyses into all serious and/or sentinel events. Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation. Manage customer satisfaction surveying. Collaborate with Risk Management regarding incidents and complaints including investigation, data gathering and data/situational analyses. Collaborate with Risk Management to align and implement strategic goals or the facility with corporate and regulatory goals. Prepare monthly and quarterly reports as required. Maintain complete confidentiality in all patient/program matters in accordance with facility policy.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

Bachelor’s degree in nursing or human services field required.  Master’s degree in nursing or human services preferred. Two or more years’ experience in Quality Management required. One or more years’ supervisory experience required. Experience in a behavioral health setting preferred. Experience with TJC accreditation and regulatory audits preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

Certifications related to health care risk management, safety, and or process improvement preferred. CPR and de-escalation/restraint certification required (training available upon hire and offered by facility).