Behavioral Health Regulatory and Quality Manager

EHS Overview Episcopal Health Services Inc. (EHS) is a health system located on the Rockaway Peninsula in Queens, New York. EHS provides inpatient, outpatient, and emergency care to the diverse populations of the Rockaways, Five Towns, South Nassau, and beyond. The system offers comprehensive preventive, diagnostic, and rehabilitative services to people of all faiths. St. John’s Episcopal Hospital is accredited by The Joint Commission’s Health Facilities Accreditation Program and is approved by the New York State Department of Health. The hospital is a recipient of the Gold‑Plus Get with the Guidelines®‑Stroke Quality Achievement Award and the Gold‑Plus Get with the Guidelines®‑Heart Failure Quality Achievement Award from the American Heart Association. Additionally, St. John’s is proud to be redesignated as a Baby‑Friendly® Hospital by Baby‑Friendly USA – the accrediting body and national authority for the Baby‑Friendly Hospital Initiative (BFHI) in the United States. Type: Full‑Time Shift: Days Hours: 8:00 AM – 4:30 PM Pay Range: $115,000. - $130,00.00 Responsibilities Responsible for supporting the development and management of quality programs and initiatives across behavioral health programs Investigate and complete RCA for all NYSOMH/Justice Center reportable events for both inpatient and outpatient behavioral health in collaboration with Risk Management Department Collaborate with leadership to ensure all corrective actions are completed. Work with the leadership team to achieve full regulatory compliance including TJC, OMH and CMS. Collaborate with hospital quality initiatives to ensure alignment for the behavioral health areas with the organization's strategic priorities. Responsible for all data collection, working with Information Technology to ensure data is collected timely and accurately. Implements routine, standardized audits of medical record documentation, environment of care, and other audits as required for inpatient behavioral health and emergency department behavioral health with the goal of facilitating standards compliance, quality of care monitoring and problem identification. Supports Behavioral Health Leadership in monitoring Hospital Based Inpatient Psychiatric Services (HBIPS) Core Measures, develops performance improvement plans, and education to drive improvement. Drive sustainable quality improvement strategies and projects, working with leadership, team members and patients /families to identify priority areas and improve outcomes. Project lead on all NYS OMH collaborative projects such as “Zero Suicide” & “PSYCKES”. Assess areas for risk potential, completing proactive risk assessments. Complete all treatment over objection for the inpatient behavioral health units. Assist in departmental performance improvement activities & projects as assigned by supervisor. Requirements Master Degree in social work, psychology, mental health counseling, nursing and applicable NYS license Three years experience in medical record review, regulatory incident management and reporting, quality data analysis, performance improvement activities and survey readiness working within behavioral health departments in licensed inpatient and/or outpatient treatment settings is required. #J-18808-Ljbffr Episcopal Health Services, Inc.