Manager of Quality and Medical Records

SCCMHA JOB VACANCY ANNOUNCEMENT

CLASSIFICATION: Manager of Quality & Medical Records

Pay Range: $82,899.44 - $107,371.73 annually

POSITION SUMMARY:

The Manager of Quality & Medical Records provides strategic leadership, departmental oversight, and direction for SCCMHA’s Quality and Medical Records Departments. This position is responsible for ensuring compliance with all federal and state regulatory requirements, leading agency wide quality improvement initiatives, overseeing medical records operations, and serving as a key advisor to the Chief Information Officer / Chief Quality & Compliance Officer. This position has independent authority to make operational decisions within the Quality and Medical Records Departments, including approval of workflows, reporting methodologies, and compliance actions.

This position functions with significant independence, exercising broad discretion in decision making, resource allocation, and operational management. The Manager develops departmental strategy in collaboration with the CIO\CQCO and is responsible for translating strategic priorities into operational plans, developing departmental strategy, establishes performance expectations, and ensures alignment with SCCMHA’s mission, accreditation standards, and statewide reporting requirements. The Manager serves as a senior member of the Business Intelligence (BI) and Quality Teams, with authority to implement process improvements, approve departmental procedures, and direct cross functional teams.

The Manager is a Primary Member of the BI Reporting Team and a core member of SCCMHA’s Quality Governance Council, responsible for high level reporting, data integrity oversight, and ensuring compliance with MDHHS, MSHN, CARF, and other regulatory bodies. Serves as a key leader in agency wide compliance, accreditation readiness, and performance improvement initiatives.

This position will be knowledgeable about and actively support culturally competent recovery-based practices; person centered planning as a shared decision-making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid persons served in the recovery process.

ESSENTIAL DUTIES AND RESPONSIBLITIES:

Strategic Leadership & Departmental Oversight

1. Provides strategic direction for the Quality and Medical Records Departments, including long range planning, resource allocation, staffing, and performance management.

2. Establishes departmental goals, KPIs, and operational standards; monitors progress and adjusts strategy as needed.

3. Develops and approves departmental policies, procedures, workflows, and documentation standards.

4. Serves as the agency’s authority on quality improvement methodology, medical records compliance, and data integrity.

5. Independently resolves complex operational, compliance, and reporting issues with minimal oversight.

6. Evaluates departmental performance through dashboards, KPIs, and audit findings; implements corrective actions without requiring supervisory approval.

7. Authorizes changes to departmental workflows, documentation standards, and reporting structures.

Quality Management & Regulatory Reporting

1. Responsible for the operations of the Quality Improvement Program.

2. Leads all Quality Improvement Projects, ensuring alignment with organizational priorities and regulatory expectations.

3. Oversees development of the Annual Quality Report & Plan.

4. Directs all Critical Incident Reporting functions, including compliance oversight, trend analysis, and reporting to MSHN and MDHHS.

5. Chairs and directs the Quality Governance Council, establishing priorities, approving project scopes, and ensuring alignment with agency strategic goals.

6. Oversees customer satisfaction survey design, distribution, analysis, and reporting.

7. Ensures compliance with all MDHHS quality data reporting requirements, including BH TEDS, MMBPIS, REMI submissions, and exception management.

8. Serves as the final reviewer for all quality submissions prior to executive approval.

Medical Records Administration

1. Provides oversight of Medical Records operations, including release of information, record maintenance, archiving, and confidentiality compliance.

2. Ensures adherence to HIPAA, 42 CFR Part 2, Michigan Mental Health Code, and SCCMHA policies.

3. Approves complex or sensitive disclosures and resolves high risk confidentiality issues.

4. Ensures medical records staff maintain accurate logs, documentation, and record integrity.

5. Oversees internal audits of persons served records and ensures corrective actions are implemented.

6. Develops and enforces agency wide standards for documentation integrity and record retention.

Business Intelligence & Data Governance

1. Serves as a senior BI leader responsible for data integrity, reporting standards, and enterprise reporting.

2. Assists with the development and maintenance of PowerBI dashboards, SSRS reports, pivot tables, and the BI Report Dictionary.

3. Provides high level data analysis for executive leadership, Board committees, and external partners.

4. Ensures compliance with all security and privacy requirements related to BI systems and reporting.

5. Acts as backup to the CIO on MSHN’s IT Council and other regional/statewide committees.

Process Improvement & Organizational Development

1. Leads agency wide process improvement initiatives using Rapid Cycle Quality Improvement methodologies.

2. Develops and delivers training for staff and network providers on quality & process improvement, data reporting, and compliance.

3. Provides consultation to leadership on performance indicators, trend analysis, and risk mitigation.

4. Oversees implementation of new quality reporting requirements and ensures EMR updates are completed.

5. Leads cross departmental process redesign efforts that impact clinical, administrative, and operational workflows.

6. Approves quality training curricula and ensures alignment with accreditation and regulatory expectations.

Cross Functional Leadership

1. Collaborates with Compliance, IT, BI, Clinical, and Administrative teams to ensure alignment of quality and medical records functions.

2. Represents SCCMHA on regional and statewide committees, workgroups, and accreditation activities.

3. Serves as a senior advisor to the CIO/CQCO on quality, compliance, and data governance matters.

4. Serves as the agency’s senior advisor on quality and medical records matters during audits, investigations, and accreditation reviews.

INCIDENTAL DUTIES AND RESPONSIBILITES:

1. Assists the CIO/CQCO with policy development, strategic planning, and organizational initiatives.

2. Presents quality and medical records reports to SCCMHA Board committees, Citizens’ Advisory Committee, and external audiences.

3. Attends required trainings, conferences, and professional development activities.

4. Attends meetings both in-person and remotely; presents to groups, facilitates meetings, creates agendas, maintains minutes, and performs needed project management tasks.

5. Attends meetings, seminars, workshops, and community events related to the public mental health mission and training sessions to maintain or upgrade current knowledge and skills required by this position and to maintain professional proficiency.

6. Provides executive level briefings to the CIO/CQCO and other leaders on departmental performance, risks, and strategic priorities.

7. May be required to commute to other SCCMHA facilities and business partners and vendor locations, when necessary, to investigate and resolve problems, implement new systems, train staff, etc.

8. May represent SCCMHA on state or regional committees and workgroups.

9. May serve as a member of various community committees, which promote the general goals of SCCMHA.

10. Must react productively and positively to change and handle other essential tasks as assigned.

11. Reads journals, periodicals, and research subjects on the Internet to increase job related knowledge and further professional and talent advancement.

12. Serves in a team setting approach by backing up other department personnel in their duties when needed.

13. Works closely with and coordinates efforts with all other agency staff and leadership as needed.

14. Works closely with and coordinates efforts with all Quality, Compliance, Business Intelligence, and Information Technology staff.

15. Provides executive level consultation to Directors and Supervisors regarding quality metrics, incident trends, and compliance risks.

16. Performs all other duties as assigned by the CIO/CQCO.

(The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all duties and responsibilities required of personnel so classified.)

REPORTING RELATIONSHIPS:

Reports to: Chief Information Officer/Chief Quality and Compliance Officer

Supervises: Quality Projects & Reporting Coordinator, Quality Improvement Program Coordinator, Quality Projects & Reporting Specialist, Typist Clerk - Medical Records

WORKING CONDITIONS/ENVIRONMENT:

1. Daily exposure in all other department areas while working with staff at their workstation locations.

2. It is not unusual to work varied and extra hours to complete assignments to meet deadlines.

3. Occasional exposure to persons served with potential for disruptive, aggressive behavior and communicable diseases.

4. Occasionally drives personal automobile on agency business to offsite facilities or meetings, sometimes in bad weather.

5. Works at workstation using keyboard and viewing computer screen for long periods.

6. Works in typical professional office environment with pressures of time constraints, multiple projects, priorities, and numerous interruptions from telephone calls and walk-ins.

7. May be required to respond to urgent quality or medical records issues outside of standard business hours.

QUALIFICATIONS:

Education: Bachelor’s degree in business administration, Applied Science, Healthcare Administration, or another closely related field. Master’s degree preferred in Business Administration, Health Administration, Quality Management, Data Analytics, or related field. A combination of skills, education, and experience, which meets organizational needs, may be considered.

Experience: Seven (7) years of progressive experience in quality management, data analytics, medical records administration, or related fields. Three (3) years of supervisory or managerial experience. Demonstrated experience leading enterpriselevel projects, regulatory reporting, and crossfunctional teams. Experience leading cross functional teams in a regulated healthcare or behavioral health environment preferred.

Licenses and Credentials: Valid Michigan Driver’s license with good driving record.

Knowledge, Skills, and Abilities:

1. Experience and demonstrated expert competency in use of Microsoft Excel.

2. Experience and demonstrated competency with data visualization related to process improvements.

3. Excellent problem solving and critical thinking skills.

4. Solid troubleshooting and communication skills.

5. Ability to demonstrate exceptional customer service skills in working with other staff, contractors, and vendors.

6. Ability to train and assist others.

7. Knowledge of mental health services.

8. Ability to maintain favorable interpersonal working relationships and positive public relations.

9. Ability to plan and organize work, perform tasks consistently and adhere to priorities.

10. Ability to produce accurate and comprehensive work products with minimal direction.

11. Ability to provide small group leadership or management.

12. Professional level verbal and written communication skills.

13. Ability to prepare content and speak to group audiences on public settings.

14. Knowledge of software applications for behavioral health provider management and managed care preferred but not required.

15. Ability to supervise staff, balance priorities & manage the departments' responsibilities.

16. Strong leadership, strategic planning, and decision making skills.

17. Ability to manage complex projects with minimal oversight.

18. Exceptional communication skills, including ability to present to executive and public audiences.

19. Ability to maintain strict confidentiality and exercise mature judgment.

20. Strong analytical, problem solving, and data interpretation skills.

21. Ability to exercise independent judgment in high risk compliance and confidentiality matters.

22. Advanced proficiency in data governance, reporting architecture, and quality analytics.

Physical/Mental Requirements:

1. Ability to handle stress in meeting deadlines and dealing with large numbers of employees and/or persons served.

2. Ability to lift boxes and equipment weighing up to 30 pounds; carry climb, stoop, bend, walk, stand, and sit for extended periods of time.

3. Ability to plan short and long range and to manage and schedule time.

4. Hearing acuity to converse in person and on telephone.

5. Manual to write and to operate standard office equipment (PC, Keyboard, Copy Machine, Fax Machine, etc.)

6. Mental capacity to think independently, follow instruction and use judgment.

7. Strong interpersonal skills to interact with leadership, employees, persons served, and the public.

8. Visual Acuity to read and proofread documents.

(Listed qualifications are for guidance in filling this position. Any combination of education and experience that provides the necessary knowledge, skills, and abilities will be considered; however, mandatory licensing or certification requirements cannot be waived. Physical/mental requirements cannot be waived unless specifically indicated.)

Employment Type: Full Time