Director of Quality and Performance

Job Description

Job Description

Quality Manager – Hickory Treatment Centers

Department: Compliance

Direct Report To: Executive Director

About the Role:

The Quality Manager is responsible for monitoring and improving the quality and safety Of services provided by the facility. This position oversees medical record quality and compliance, supports patient rights activities, monitors incidents and complaints, and assists leadership in identifying opportunities for continuous improvement.

Under the immediate supervision of the Executive Director, the Quality Manager will assess the facility's quality assurance, performance improvement, medical records, patient rights, and regulatory compliance activities.

Why Hickory Recovery? 

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 

Our Mission

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. 

 

What We Offer: 

• 401k

• Dental insurance

• Flexible schedule 

• Health insurance 

• PTO 

• Vision insurance 

• Career development 

• Mental health days 

• Holiday pay 

 

Job Qualifications:  

• 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

Key Responsibilities:

Quality Improvement & QAPI

• 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.

Medical Records & Documentation

• 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.

Patient Rights & Grievances

• 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.

Regulatory Compliance & Safety Readiness

• 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.

Corrective Action & Performance Monitoring

• 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.

Staff Education & Training

• 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.

General Quality & Compliance Responsibilities

• 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.

Compensation:

$60,000 – 65,000 annually

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