Quality Improvement Specialist

Overview Schedule: Monday to Friday, 8am-4pm Join a Team That Changes Lives For more than 170 years, Elwyn has been leading the way in supporting children, teens, and adults with autism, intellectual and developmental disabilities, and behavioral health challenges. As a mission-driven nonprofit, we're here to create real change - helping people lead meaningful, fulfilling lives. Now, we're looking for passionate team members to join us. Here, your work will change lives - including your own. You'll make an impact every day, find purpose in what you do, and grow in a career that truly matters. At Elwyn, we take care of you while you care for others. We offer: 1. Generous Paid Time Off 2. Comprehensive Medical/Dental/Vision Benefit Packages 3. Earned Wage Access/On-Demand Pay 4. Paid On-the-Job Training 5. Tuition Reimbursement 6. Career Advancement Opportunities and Growth 7. Flexible Schedules 8. Retirement Savings Plan Join us and be a part of something bigger. Apply today. Job Description POSITION SUMMARY: The Quality Improvement Coordinator conducts internal evaluations of services to ensure quality care which fulfills all regulatory, funding agency, and internal standards; performs assessments of all services and make recommendations for improvement in all aspects of service delivery; and develops and implements policies for assuring compliance with all fire, health, safetys and security regulations. DUTIES AND RESPONSIBILITIES: 1. Conduct internal evaluations for the assigned Adult Behavioral Health programs including, but not limited to: 2. Self-initiate Quality Improvement (QI) and Quality Assurance (QA) projects to aid in Elwyn's on-going commitment to the delivery of exceptional services as indicated through internal evaluations 3. Conduct reviews/audits of program plans and related documents for compliance with professional quality and regulatory standards 4. Conduct chart audits to ensure quality of services delivered to clients and compliance with Managed Care Organization (MCO) policies as well as to ensure compliance with licensing regulations 5. Present chart audit findings or other relevant information to program leadership on a monthly basis, as a summary email, requesting in-person or virtual meetings based on findings, as needed 6. Create effective internal control procedures based on audit findings 7. Report Quality Improvement needs to the Director of QI based on internal evaluations, and chart audits, providing recommendations for process improvement 8. Evaluate all aspects of programming and ensure all policies and procedures are followed and enforced 9. Obtain and maintain current Certified Investigator (CI) training and credentialing 10. Complete investigations of incidents, as assigned, with tasks including but not limited to interviewing complainant, witnesses, and targets; visit site for investigation inspections; review any collateral records as indicated; preserve all evidence and maintain appropriate chain of custody; author comprehensive report of all investigation findings; and facilitate investigation debriefing and wrap-up with program leadership and Human Resources 11. Develop, implement, and monitor plans of correction as assigned; assist the QI Director with building processes and systems to prevent recurrence of identified issues 12. Participate in the development of policies and procedures regarding utilization management, facility safety, and fire safety, in cooperation with the Director of QI and program leadership, based on Office of Mental Health and Substance Abuse Services (OMHSAS ) standards 13. Attend Elwyn and community-based committees and sub-committees, as assigned, looking for opportunities for process and policy improvement for the programs supported 14. Conduct interviews and surveys with individuals supported, their families/guardians, staff members, advocates, etc. to ve ify that quality services are being delivered, and the program is meeting customer needs 15. Provide in-service trainings for all Adult Behavioral Health staff to support compliance, program development, and thorough understanding of all program regulations 16. Answer all questions regarding forms, policies, and protocols in regards to the annual program plan writing, implementation, revision, and training 17. Maintain records of all compliance documentation and survey results as required under policy 18. Maintain confidential program staff credentialing files and training records at the program location, under lock and key 19. Run and review training reports using the Elwyn computer database to make sure staff are compliant and up to date on all required trainings based on program regulations 20. Support registration and scheduling of Elwyn staff and other third-party support resources for Elwyn training (eLMS), in cooperation with Elwyn Learning & Staffing Development, and the Clinical Coordinator; provide reports of missed trainings to Director of QI and program leadership to ensure trainings are completed, to maintain compliance, and to maintain exceptional resident care 21. Determine, by a monthly review of the exclusion list database, if Elwyn employees are noted; conduct due diligence based on any employees found on the list (e.g. coordinate with Risk Management and Human Resources, meet with the employee) 22. Review, update, and maintain a current file of all QI tools used as part of continuous quality improvement (CQI), including but not limited to tools for chart, medication audit, physical site, finance, and data audits 23. Maintain up-to-date knowledge of all regulations and MCO policies through participation in external training offerings and review of regulatory body communications, communicating changes to the program, and keeping all programming policies and procedures current; maintain a current file of all program regulatory standards and updates 24. Monitor program compliance with federal, state, local, and managed care organization's (MCO) regulations as applicable, reporting any deficiencies to the Director 25. Compare treatment notes to billing records, on a monthly basis at minimum, to verify time spent on each case for billing to payers 26. Enter information concerning incidents in the current incident management system for reporting and analysis purposes 27. Perform cardiopulmonary resuscitation (CPR), first aid, and crisis intervention using agency-trained protocols 28. Perform other duties as assigned IMMEDIATE SUPERVISOR: Director of Qua