Behavioral Health Regulatory and Quality Manager

Job Description

Job Description

Who We Are:

St. John’s Episcopal Hospital is the only hospital providing emergency and ambulatory care to the densely populated, culturally and economically diverse, and medically underserved populations of the Rockaways and Five Towns in southern Queens County and southwestern Nassau County, New York. Celebrating over 110 years of community care, the 257-bed facility provides people of all faiths with comprehensive preventive, diagnostic treatment and rehabilitative services, regardless of ability to pay.

Come Grow With Us!

Type: Full-Time

Shift: Days

Hours: 8:00AM – 4:30PM

Pay: $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 license if required.
• 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.