Director of Quality and Performance

Hickory Recovery is setting the benchmark in mental health care, especially for those facing acute challenges or dealing with co-occurring disorders. Our focus is on  

•    Delivering personalized, top tier care that fosters healing and improves wellbeing 

•    Ensuring every individual has access to the best possible support and treatment 

To provide high quality, acute care for adults struggling with mental health issues or mental health co-occurring disorders. It’s Hickory’s primary goal to offer expert treatment for all we serve. 

•    Bachelor's degree in healthcare administration, Nursing, Social work, Quality Management, Business Administration or related field ; master's degree preferred.

•    Must have Registered Health Information Administrator (RHIA) certification

•    Experience in healthcare, behavioral health, psychiatric, residential, risk management, or performance improvement

•    Experience with quality assurance, compliance, medical records, risk management

•    Knowledge of documentation standards and confidentiality requirements

•    Ability to work effectively in a fast-paced, team-oriented environment.

•    Ability to handle confidential information with discretion

•    Ability to conduct audits, analyze data, identify trends, and develop recommendations

•    Support organizational efforts related to quality, safety, risk management, and regulatory compliance.

•    Collaborate with leadership and interdisciplinary teams to address quality and compliance concerns.

•    Participate in quality and performance improvement initiatives as assigned.

•    Collect, track, trend, and analyze quality data and performance indicators.

•    Identify areas of risk, deficiencies, adverse trends, and opportunities for improvement.

•    Prepare QAPI reports, dashboards, summaries, and presentations for leadership and applicable committees.

•    Coordinate and maintain quality-improvement documentation and supporting evidence.

•    Participate in quality, safety, risk-management, and performance-improvement meetings.

•    Conduct audits and provide feedback to departments regarding identified deficiencies and opportunities for improvement.

•    Promote staff accountability and continuous quality improvement.

•    Oversee the quality, completeness, accuracy, organization, and timeliness of patient medical records.

•    Conduct routine and focused medical record audits to identify documentation deficiencies.

•    Monitor records for completion of required assessments, treatment plans, progress notes, orders, consents, discharge documentation, and other required clinical records.

•    Track medical record deficiencies and communicate findings to appropriate department leaders.

•    Monitor appropriate access, release, retention, storage, and disposal of medical records in accordance with applicable requirements and facility policy.

•    Prepare medical record audit reports for leadership and quality committees.

•    Work collaboratively with leadership and staff to improve documentation practices.

•    Ensure patients receive information regarding their rights, responsibilities, grievance procedures, privacy, and available advocacy resources.

•    Monitor compliance with patient rights policies and procedures.

•    Receive, document, track, and coordinate follow-up on patient grievances and complaints.

•    Ensure grievances are investigated and addressed in a timely, objective, and appropriate manner.

•    Maintain a grievance log and identify trends requiring corrective or performance-improvement action.

•    Monitor for potential violations of patient rights and escalate concerns appropriately.

•    Assist patients in understanding the grievance and complaint process without fear of retaliation.

•    Coordinate with leadership and appropriate clinical staff when patient rights concerns require immediate intervention.

•    Maintain documentation related to grievances, investigations, resolutions, and follow-up activities.

•    Maintain compliance with applicable federal, state, and local laws, licensing requirements, accreditation standards, and regulatory requirements.

•    Maintain current knowledge of applicable behavioral health and healthcare quality standards.

•    Conduct internal compliance audits and monitoring activities.

•    Assist with the development and revision of policies and procedures based on regulatory and quality requirements.

•    Maintain organized records and evidence needed for regulatory and accreditation surveys.

•    Assist with preparation for regulatory, accreditation, certification, and licensing surveys.

•    Participate in survey preparation and survey activities.

•    Track regulatory findings and monitor implementation of plans of correction.

•    Assist managers and supervisors in understanding audit findings and implementing corrective actions.

•    Monitor identified deficiencies and corrective action plans to ensure appropriate follow-through.

•    Identify recurring issues and trends requiring additional intervention or performance improvement.

•    Monitor compliance with facility policies, procedures, standards, and applicable regulatory requirements.

•    Provide education and training to staff regarding documentation, patient rights, quality standards, compliance, incident reporting, and QAPI processes.

•    Assist managers and supervisors with understanding quality and compliance expectations.

•    Participate in orientation and ongoing education related to quality and compliance as assigned.

•    Promote staff accountability and adherence to quality and regulatory standards.

Learn More

https://hickorytreatmentcenters.com