DIRECTOR OF QUALITY ASSURANCE
DEFINITION:
Under the direction of the chief executive officer or other administrative official in a state department, institution, or agency, at a facility in the NJ Department of Human Services or the NJ Department of Health, has responsibility for developing and managing all components of the institutional quality assurance performance improvement system; additionally, is charged with the administrative supervision of Program Evaluation, Patient Safety, Utilization Review, Risk Management, Pre-Accreditation Review, Medical Records, Information System Management, Disciplinary Standards, and Professional Growth and Development Standards; performs related duties as required.
NOTE: The examples of work for this title are for illustrative purposes only. A particular position using this title may not perform all duties listed in this job specification. Conversely, all duties performed on the job may not be listed.
EXAMPLES OF WORK:
Plans, organizes, and assigns the work of the organizational unit, and evaluates employee performance and conduct, enabling the effective recommendation of the hiring, firing, promoting, and disciplining of subordinates.
Collaborates with the chief executive officer, assistant hospital administrator, clinical director, and/or medical director to develop, implement, and monitor a facility-wide quality assurance performance improvement program. This program ensures compliance with the regulations outlined in Titles 5, 18, and 19 of Public Law 89-97 (Social Security Amendments of 1965) and adherence to Title 20 of the Social Security Act and Title 45 of the Code of Federal Regulations. Additionally, the role involves ensuring compliance with the standards set by the Joint Commission on the accreditation of hospitals (TJC), the regulations of the Professional Standards Review Organization (P.S.R.O.), and the established guidelines from the U.S. Department of Health (HHS), the NJ Department of Human Services (NJDHS), and the NJ Department of Health (NJDOH), as well as hospital policies.
Oversees quality assurance plans and programs, including conducting utilization reviews, utilizing Program Analysis of Service Systems (PASS) methods, and evaluating how social service programs align with patient normalization principles. Additionally, the director will manage a psychiatric medical audit system, conduct individual morbidity and mortality care reviews, assess risk management programs, and implement best practices for mitigating medical record deficiencies. Ensures the facility's quality assurance plan aligns with state and federal standards and requirements established by accrediting, approving, governing, and/or reviewing bodies for best practices related to patient care.
Supervises establishing and monitoring professional standards for patient care and services through unit, division, and department heads. Ensures the delivery of quality treatment to patients and adherence to professional standards.
Establishes collaboration among the administrative, clinical, medical, and social rehabilitative components within the facility.
Coordinates and monitors facility-wide programs and organizational objectives for compliance with Medicaid, TJC standards, and NJ Division of Behavioral Health Services surveys. Additionally, collaborates with staff to interpret plans, establish deadlines, and achieve the goals set by these standards with measurable outcomes.
Develops methods of keeping staff and stakeholders informed about Medicare and Medicaid standards, TJC surveys, and performance measures. This includes areas such as utilization review, program evaluation, professional growth, disciplinary standards, root cause analysis, risk assessment and mitigation strategies, patient safety, patterns and trends, and medical records management; may serve as an arbiter, standards reviewer, statistical data analyzer, resource, and consultant to high-level administrative and clinical staff.
Coordinates employee competency and training initiatives to ensure continuous growth and skill development; integrates a comprehensive training plan for the facility's quality assurance performance improvement program. If residency programs exist, collaborates closely with the medical director to achieve established goals and objectives.
Coordinates and monitors facility-wide corrective action plans resulting from evaluations and surveys conducted by various bodies, including the Center for Medicare and Medicaid (CMS), TJC, HHS, NJDOH, and the Bureau of Standards and Inspections within the Division of Behavioral Health Services at the NJDHS. This role involves collaborating with senior and support staff throughout the organization and facility to develop, implement, and closely monitor these corrective plans. Additionally, ensures timely communication with surveying bodies regarding ongoing corrective actions as needed.
Responsible for overseeing the credentialing and privileging processes.
Conducts yearly assessments of the facility's quality assurance performance improvement plan, makes necessary modifications, and develops written criteria for measuring compliance with achieved goals; implements action plans in response to various issues, including staff education, policy development, employee engagement, operational changes, and adjustments to professional provisions.
Develops a quality assurance performance improvement program component that identifies issues, prioritizes analysis, and ensures objective assessment. This involves adhering to specification standards and appropriate sampling methods.
Develops, implements, and oversees facility-wide corrective action plans to address issues identified through surveys, reports, and safety incidents; trains clinicians and support personnel in quality assessment techniques, including criteria development, data retrieval, analysis, and problem reporting -all while maintaining confidentiality.
Oversees adherence to employee disciplinary standards related to patient care and services. The primary goal is to ensure the provision of quality treatment while upholding professional standards.
Provides recommendations to the chief executive officer concerning the optimal structure and composition of quality assurance performance improvement committees. These committees may cover utilization review, medical records, accreditation, root cause analysis, and other pertinent boards and panels.
Supervises and coordinates steering committees, providing guidance and direction to facility staff, across various departments, units, sections, service areas, and disciplines.
May develop and maintain a quality assurance monitoring system for specific activities within the facility, aligning it with the organizational structure.
Directs the establishment and maintenance of essential records and files.
Will be required to learn how to utilize various types of electronic and/or manual recording and computerized information systems used by the health discipline, public health administration, or hospital administration.
REQUIREMENTS:
EDUCATION:
A doctoral degree from an accredited college or university in a mental health discipline, psychiatric nursing, public health administration, or hospital administration.
NOTE: A valid license to practice medicine in the State of New Jersey may be substituted for the above-referenced education.
EXPERIENCE:
Five (5) years of experience in mental health-related research, teaching, or the provision and/or administration of mental health services, including two (2) years of supervisory experience. AND:
Two (2) years of experience in the NJ Department of Human Services or the NJ Department of Health Quality Assurance Programs consisting of one or more of the following areas: program evaluation, utilization review, accreditation compliance, disciplinary standards, medical records, professional growth and development service, standards compliance, or their equivalent.
NOTE: A master's degree from an accredited college or university in a mental health discipline, psychiatric nursing, public health administration, or hospital administration supplemented by two (2) additional years of experience in mental health-related research, teaching, or the provision and/or administration of mental health services may be substituted for the doctoral degree.
LICENSE:
Appointees will be required to possess a driver's license valid in New Jersey only if the operation of a vehicle, rather than employee mobility, is necessary to perform the essential duties of the position.
KNOWLEDGE AND ABILITIES:
Knowledge of the principles and procedures for quality assurance performance improvement in behavioral health systems.
Knowledge of laws, regulations, standards, policies, and programs of state, federal, and accrediting agencies related to quality assurance, and performance improvement systems.
Knowledge of modern program evaluation practices, including establishing and monitoring an information management system.
Knowledge of quality assurance performance improvement best practices and the ability to establish standards consistent with TJC, CMS, HHS, FEMA, the U.S. Office of the Inspector General (OIG), NJDOH, and NJDHS mandates after a training period.
Knowledge of modern program evaluation practices, including establishing and maintaining a comprehensive information management system.
Knowledge of utilization and review methods, medical records requirements, and the ability to organize and lead staff in implementing new and enhanced quality assurance performance improvement plans and failure mode effects analysis.
Knowledge of supervisory methods and techniques, including conflict resolution and mediation.
Knowledge of methods used to establish a data collection system for recording and reporting on quality assurance performance improvement activities within behavioral health hospitals.
Knowledge of procedures and protocols for conducting executive-level meetings.
Ability to supervise staff in quality assurance performance improvement programs, including establishing and monitoring an information management system, as well as organizational planning for short- and long-term goals.
Ability to analyze and interpret laws and regulations about quality assurance performance improvement in behavioral health hospitals, and apply them effectively in a clinical setting.
Ability to make complex policy decisions affecting the operations of a psychiatric hospital and related behavioral health services.
Ability to plan and supervise surveys, studies, and investigations, and effectively report findings.
Ability to collaborate with supervisors, peers, federal, state, and local officials, physicians, and representatives of health, educational, and community programs to promote quality patient care and services.
Ability to conduct meetings and give presentations before lay and professional groups.
Ability to compose detailed correspondence and prepare clear, sound, accurate, and informative reports on mental health programs.
Ability to direct the establishment and maintenance of essential records and files.
Ability to conduct training, workshops, study groups, and other training activities on quality assurance.
Ability to learn how to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
Ability to read, write, speak, understand, and communicate in English sufficiently to perform the duties of this position. American Sign Language or Braille may also be considered as acceptable forms of communication.
Persons with mental or physical disabilities are eligible if they can perform the essential functions of the job with or without reasonable accommodation. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible.
JobUnder the direction of the chief executive officer or other administrative official in a state department, institution, or agency, at a facility in the NJ Department of Human Services or the NJ Department of Health, has responsibility for developing and managing all components of the institutional quality assurance performance improvement system; additionally, is charged with the administrative supervision of Program Evaluation, Patient Safety, Utilization Review, Risk Management, Pre-Accreditation Review, Medical Records, Information System Management, Disciplinary Standards, and Professional Growth and Development Standards; performs related duties as required.
","NOTE":"The examples of work for this title are for illustrative purposes only. A particular position using this title may not perform all duties listed in this job specification. Conversely, all duties performed on the job may not be listed.\n\nA valid license to practice medicine in the State of New Jersey may be substituted for the above-referenced education. \n\nA master's degree from an accredited college or university in a mental health discipline, psychiatric nursing, public health administration, or hospital administration supplemented by two (2) additional years of experience in mental health-related research, teaching, or the provision and/or administration of mental health services may be substituted for the doctoral degree.\n\n SCNL33N/AM33-Plans, organizes, and assigns the work of the organizational unit, and evaluates employee performance and conduct, enabling the effective recommendation of the hiring, firing, promoting, and disciplining of subordinates.
Collaborates with the chief executive officer, assistant hospital administrator, clinical director, and/or medical director to develop, implement, and monitor a facility-wide quality assurance performance improvement program. This program ensures compliance with the regulations outlined in Titles 5, 18, and 19 of Public Law 89-97 (Social Security Amendments of 1965) and adherence to Title 20 of the Social Security Act and Title 45 of the Code of Federal Regulations. Additionally, the role involves ensuring compliance with the standards set by the Joint Commission on the accreditation of hospitals (TJC), the regulations of the Professional Standards Review Organization (P.S.R.O.), and the established guidelines from the U.S. Department of Health (HHS), the NJ Department of Human Services (NJDHS), and the NJ Department of Health (NJDOH), as well as hospital policies.
Oversees quality assurance plans and programs, including conducting utilization reviews, utilizing Program Analysis of Service Systems (PASS) methods, and evaluating how social service programs align with patient normalization principles. Additionally, the director will manage a psychiatric medical audit system, conduct individual morbidity and mortality care reviews, assess risk management programs, and implement best practices for mitigating medical record deficiencies. Ensures the facility's quality assurance plan aligns with state and federal standards and requirements established by accrediting, approving, governing, and/or reviewing bodies for best practices related to patient care.
Supervises establishing and monitoring professional standards for patient care and services through unit, division, and department heads. Ensures the delivery of quality treatment to patients and adherence to professional standards.
Establishes collaboration among the administrative, clinical, medical, and social rehabilitative components within the facility.
Coordinates and monitors facility-wide programs and organizational objectives for compliance with Medicaid, TJC standards, and NJ Division of Behavioral Health Services surveys. Additionally, collaborates with staff to interpret plans, establish deadlines, and achieve the goals set by these standards with measurable outcomes.
Develops methods of keeping staff and stakeholders informed about Medicare and Medicaid standards, TJC surveys, and performance measures. This includes areas such as utilization review, program evaluation, professional growth, disciplinary standards, root cause analysis, risk assessment and mitigation strategies, patient safety, patterns and trends, and medical records management; may serve as an arbiter, standards reviewer, statistical data analyzer, resource, and consultant to high-level administrative and clinical staff.
Coordinates employee competency and training initiatives to ensure continuous growth and skill development; integrates a comprehensive training plan for the facility's quality assurance performance improvement program. If residency programs exist, collaborates closely with the medical director to achieve established goals and objectives.
Coordinates and monitors facility-wide corrective action plans resulting from evaluations and surveys conducted by various bodies, including the Center for Medicare and Medicaid (CMS), TJC, HHS, NJDOH, and the Bureau of Standards and Inspections within the Division of Behavioral Health Services at the NJDHS. This role involves collaborating with senior and support staff throughout the organization and facility to develop, implement, and closely monitor these corrective plans. Additionally, ensures timely communication with surveying bodies regarding ongoing corrective actions as needed.
Responsible for overseeing the credentialing and privileging processes.
Conducts yearly assessments of the facility's quality assurance performance improvement plan, makes necessary modifications, and develops written criteria for measuring compliance with achieved goals; implements action plans in response to various issues, including staff education, policy development, employee engagement, operational changes, and adjustments to professional provisions.
Develops a quality assurance performance improvement program component that identifies issues, prioritizes analysis, and ensures objective assessment. This involves adhering to specification standards and appropriate sampling methods.
Develops, implements, and oversees facility-wide corrective action plans to address issues identified through surveys, reports, and safety incidents; trains clinicians and support personnel in quality assessment techniques, including criteria development, data retrieval, analysis, and problem reporting -all while maintaining confidentiality.
Oversees adherence to employee disciplinary standards related to patient care and services. The primary goal is to ensure the provision of quality treatment while upholding professional standards.
Provides recommendations to the chief executive officer concerning the optimal structure and composition of quality assurance performance improvement committees. These committees may cover utilization review, medical records, accreditation, root cause analysis, and other pertinent boards and panels.
Supervises and coordinates steering committees, providing guidance and direction to facility staff, across various departments, units, sections, service areas, and disciplines.
May develop and maintain a quality assurance monitoring system for specific activities within the facility, aligning it with the organizational structure.
Directs the establishment and maintenance of essential records and files.
Will be required to learn how to utilize various types of electronic and/or manual recording and computerized information systems used by the health discipline, public health administration, or hospital administration.
","REQUIREMENTS":"","EDUCATION":"A doctoral degree from an accredited college or university in a mental health discipline, psychiatric nursing, public health administration, or hospital administration.
","EXPERIENCE":"Five (5) years of experience in mental health-related research, teaching, or the provision and/or administration of mental health services, including two (2) years of supervisory experience. AND:
Two (2) years of experience in the NJ Department of Human Services or the NJ Department of Health Quality Assurance Programs consisting of one or more of the following areas: program evaluation, utilization review, accreditation compliance, disciplinary standards, medical records, professional growth and development service, standards compliance, or their equivalent.
","LICENSE":"Appointees will be required to possess a driver's license valid in New Jersey only if the operation of a vehicle, rather than employee mobility, is necessary to perform the essential duties of the position.
","KNOWLEDGE_AND_ABILITIES":"Knowledge of the principles and procedures for quality assurance performance improvement in behavioral health systems.
Knowledge of laws, regulations, standards, policies, and programs of state, federal, and accrediting agencies related to quality assurance, and performance improvement systems.
Knowledge of modern program evaluation practices, including establishing and monitoring an information management system.
Knowledge of quality assurance performance improvement best practices and the ability to establish standards consistent with TJC, CMS, HHS, FEMA, the U.S. Office of the Inspector General (OIG), NJDOH, and NJDHS mandates after a training period.
Knowledge of modern program evaluation practices, including establishing and maintaining a comprehensive information management system.
Knowledge of utilization and review methods, medical records requirements, and the ability to organize and lead staff in implementing new and enhanced quality assurance performance improvement plans and failure mode effects analysis.
Knowledge of supervisory methods and techniques, including conflict resolution and mediation.
Knowledge of methods used to establish a data collection system for recording and reporting on quality assurance performance improvement activities within behavioral health hospitals.
Knowledge of procedures and protocols for conducting executive-level meetings.
Ability to supervise staff in quality assurance performance improvement programs, including establishing and monitoring an information management system, as well as organizational planning for short- and long-term goals.
Ability to analyze and interpret laws and regulations about quality assurance performance improvement in behavioral health hospitals, and apply them effectively in a clinical setting.
Ability to make complex policy decisions affecting the operations of a psychiatric hospital and related behavioral health services.
Ability to plan and supervise surveys, studies, and investigations, and effectively report findings.
Ability to collaborate with supervisors, peers, federal, state, and local officials, physicians, and representatives of health, educational, and community programs to promote quality patient care and services.
Ability to conduct meetings and give presentations before lay and professional groups.
Ability to compose detailed correspondence and prepare clear, sound, accurate, and informative reports on mental health programs.
Ability to direct the establishment and maintenance of essential records and files.
Ability to conduct training, workshops, study groups, and other training activities on quality assurance.
Ability to learn how to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
Ability to read, write, speak, understand, and communicate in English sufficiently to perform the duties of this position. American Sign Language or Braille may also be considered as acceptable forms of communication.
Persons with mental or physical disabilities are eligible if they can perform the essential functions of the job with or without reasonable accommodation. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible.
Job