The Behavioral Health Quality Manager is responsible for supporting the development and management of quality and safety programs and initiatives across Bon Secours Charity System behavioral health programs. This position collects and reports data to analyze metrics in collaboration with program staff. In addition, this position facilitates incident investigation, reporting to regulatory agencies as required and conducts analyses of events.

RESPONSIBILITIES:

• Implements routine, standardized audits of medical record documentation, environment of care, and other audits as required for inpatient mental health, psychiatric ED, and outpatient MH treatment programs with the goal of facilitating standards compliance, quality of care monitoring and problem identification.
• Works in collaboration with hospital managers and staff to ensure regulatory compliance and continued readiness for surveys including, but not limited to Centers for Medicare and Medicaid (CMS), Joint Commission, NYS Department of Health (DOH), NYS Office of Mental Health (OMH), NYS Justice Center, Office of Addiction Services and Supports (OASAS) and others, as applicable.
• Tracks the completion of corrective action plans.
• Supports Psychiatric Leadership in monitoring Hospital Based Inpatient Psychiatric Services (HBIPS) Core Measures, develops performance improvement plans, and education to drive improvement.
• Collects, analyzes, reports, and coordinates the improvement of key performance indicators for the behavioral health service line.
• Participates in Incident Review Committee and assists in tracking trends and corrective action plans.
• Participates in incident investigation and conducts interviews and analysis, completes all reporting to regulatory agencies as needed (Justice Center, NIMRS system, NYPORTS, OMH, and OASAS).
• Manages high risk behavioral health policies, ensuring they are accurate and up to date.
• Performs other duties as assigned.

QUALIFICATIONS / REQUIREMENTS:

Experience:

Bachelor's Degree in a health/mental health related discipline with three years' experience in medical record review, incident management or reporting, quality data analysis and presentation, and survey readiness experience; or

A bachelor's degree in a health/mental health related discipline with three years' of supervisory or managerial experience in a behavioral health program, 2 years of which must have included quality assessment and performance improvement activities; or

A Master's degree in a health/mental health related discipline with two years' experience in a behavioral health program, one year of which must have included quality assessment and performance improvement activities experience

Education:

Bachelor's Degree in a health/mental health related discipline, required.

Licenses / Certifications:

CPHQ preferred.

Other:

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood

and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

About Us:

Good Samaritan Hospital

Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area's leading Wound and Hyperbaric Institute and outstanding maternal/child services that includes a Children's Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric and substance-abuse services and its certified home-care agency supports residents of the Hudson Valley and beyond.