Job Description

OBJOB SUMMARY:

Under the general supervision of the Vice President QA/QI, the Quality Assurance and Improvement Specialist promote conformance to standards and quality improvement in ICL and affiliate programs through ongoing monitoring, evaluation, consultation, education and the development of quality-related products and processes.

ESSENTIAL JOB FUNCTIONS:

Essential Job Functions:

1. Monitoring and Evaluation Activities

• Conduct quality audits of ICL and affiliate program sites on a monthly, quarterly, annual or as needed basis to determine conformance to regulatory agency, accrediting agency and ICL standards for service
• Conduct audits of the implementation of plans of corrective action that have been developed by programs in response to statements of deficiencies pursuant to regulatory agency program
• Conduct clinical case or business record reviews.
• Conduct physical plant surveys.
• Conduct employee interviews.
• Conduct recipient interviews.
• Conduct billing compliance audits;
• Conduct contract compliance audits as appropriate.
• Assist in the administration of various department quality assurance and improvement information systems where administration includes responsibility for data entry, reliability of database records, and statistical and other reports that produced from the database including but not limited Consumer evaluation
• Participate in reviews and analyses of quality-of-care-related data and program- performance data to determine progress toward stated goals and
• Participate in ICL and affiliate incident management programs:
• Conduct special investigations of serious reportable incidents and allegations of
• Participate in the maintenance of ICL and oversight agency databases by entering data from incident reports and producing reports from the databases; and
• Generate Incident Review Committee meeting agenda and other reports on an as needed
• Participate in the design, production and use of quality assurance and improvement instruments (e.g. internal audit tools) and quality improvement products (e.g. manuals, training guides)
• Issue requested management reports on identified quality assurance and improvement performance and outcome indicators.

Consultation Activities

• Assist ICL and affiliate program managers and staff in preparation for accreditation and
• Assist ICL and affiliate program managers with achieving conformance to Federal, State, City and accreditation agency standards through participation in planning activities and development of quality and compliance-related products
• Participate in development of ICL and affiliate electronic clinical information systems, providing consultation to program staff in use of the agency's EHR to construct assessments, treatment plans, and quality audit products;
• Engage in problem-solving activities with program managers and/or staff to improve program effectiveness and the quality of care.

Educational Activities

• Participate in design and delivery of workshops and other educational materials to program managers and staff that provide knowledge and information on accrediting, regulatory and professional standards and practices that pertain to evidence-based service delivery and quality of care for existing and new
• Represent the agency at relevant conferences by designing and presenting educational materials and activities that promote continuous quality
• Participate in or conduct or coordinate root cause analyses on sentinel and other significant events in programs on an as needed.

Relationships with Others in the Agency

• Consult with program directors and residence managers to develop and execute quality improvement plans, including plans of corrective action (POCAs) for certification visits and internal agency audit
• Participate in program planning projects and meetings to provide input on development of quality control and program evaluation
• Conduct or participate in management meetings with service-delivery program managers to establish, delineate, and review program organizational policies, to coordinate functions and operations between departments, and establish responsibilities and procedures for attaining objectives and assist with the implementation of new programs.
• Perform other related duties as assigned.

ESSENTIAL KNOWLEDGE, SKILLS AND ABILITIES:

• Committed to the active promotion of ICL values and goals.
• Knowledge of Federal, New York State and New York City regulations pertaining to the operation of programs that provide mental health and/or intellectual/developmental disabilities
• Knowledge of psychiatric rehabilitation interventions and accepted practices for documenting related services
• Auditing skills
• Effective organizational skills (e.g. planning, scheduling, prioritizing tasks)
• Ability to meet all deadlines
• Effective presentation skills (e.g. prepare and deliver a written or spoken presentation with supporting materials)
• Effective problem-solving skills
• Effective interpersonal skills
• Strong analytical skills
• The ability to interpret legal requirements
• The ability to accurately interpret and implement regulatory standards
• An ability to gather, analyze and evaluate facts and to prepare and present concise oral and written reports
• Ability to express self clearly both verbally and in writing
• Ability to work as a member of a team
• Ability to work independently
• Ability and interest in working with diverse employees and recipients of services
• Consultation experience
• Experience designing and presenting training workshops
• Report-writing skills
• Knowledge of computer-based software including Microsoft Office components

QUALIFICATIONS AND EXPERIENCE:

• Bachelor of Arts in psychology, education, social work or related field and at least three years' experience working in a behavioral health setting (preferably in residential services). For positions auditing IDD programs, the experience must be working in a setting providing services to individuals with intellectual and/or developmental disabilities. For positions auditing mental health programs, the experience must be working in a setting providing services to individuals with mental illness.
• A Master's degree in a related field may be substituted for two years of the above experience. NYS driver's license very desirable.