Performance Improvement Coordinator

Summary The Performance Improvement Coordinator in behavioral health drives quality care by analyzing clinical data, monitoring compliance with Federal/State regulations for licensure, accreditation, and certification (NJ-DOH, NJ-DMHAS, Joint Commission, CCBHC), addressing any deficits, and leading performance improvement projects to improve client outcomes. The PI Coordinator proactively develops, implements, coordinates, and monitors a Center-wide Performance Improvement process with activities including the facilitation of monthly and quarterly performance improvement meetings, assisting staff in learning about, analyzing, and reporting on data collection within programs/departments, and implementing a comprehensive plan for improvement agency-wide. Is responsible for the coordination, development, implementation, and monitoring of activities that ensure licensure and accreditation remain in good standing through cooperation with the Management Team and supervisory staff. This includes the promulgation of policies and procedures necessary to comply with applicable Federal, State, and Joint Commission requirements and best practices. Serves as administrator for data management through systems such as the

DMHAS QCMR

portal, JC AMP, and others as assigned. Essential Functions Actively supports, monitors, and prepares for Joint Commission, DOH, and/or MCO audit activities to ensure continual compliance and adherence to funding, regulatory, and reimbursement (medically necessary) requirements. Reinforces

DMHAS, DAS, JC, HIPAA/HITECH

standards by maintaining written documentation on random inspections and conducting mock surveys, providing modeling, coaching, and training as necessary Serves as PI Core Committee Chair, coordinating and implementing activities required for PI activities, Staff Education process and the annual Performance Improvement Plan creation. Assists clinical teams/staff/supervisors in their PI/QA efforts to identify and determine (corrective) actions to address performance issues, evaluate/promote successful clinical treatment outcomes (i.e., successful discharge), as well as other Center Activities. Maintains a record of all relevant data and assists in the development of tools to facilitate the collection of data in a PI Dashboard, keeping staff accountable to work-related expectations for Performance Improvement Collects information needed to develop and support the organization-wide PI plan and assists in relating data to regulatory agency requirements (JC, State, Federal, and licensing agencies) as well as key community stakeholders while balancing conflicting organizational needs Analyzes data to identify trends, make recommendations for program improvement, assist in risk mitigation activities and problem solve identified trends/patterns of gaps in quality care, service, and safety across the agency Monitor utilization and service quality through (ongoing/episodic etc.) medical necessity, HEDIS quality measure reviews (audits), ensuring compliance and providing staff with any updates or changes in funder requirements/expectations. Ensures Center staff compliance with mandatory training and credentialing, managing documentation requirements Maintains effective customer satisfaction program by implementing surveys, face to face meting etc. with the goal of gathering feedback about Center effectiveness, efficiency and perception of care with analysis of results to identify gaps, issues, and opportunities for improvement and recommends necessary corrective action steps to Management Responsible for the oversight and coverage of the orientation of staff with the Quality Assurance Specialist Assumes responsibility of QA Specialist for coverage as assigned/needed Performs other related duties as assigned Essential Qualifications Master's degree in Mental Health or related field (Social Work; Psychology or related field) Working knowledge of outcome measures, performance improvement methods and ability to communicate/teach these topics Proficient in Microsoft office applications Working knowledge of

DMHAS, DAS, JC, HIPAA/HITECH

Advanced verbal and written communication skills, meeting facilitation skills Possession of a Valid NJ driver's license in good standing Preferred Qualifications Professional Licensure (LCSW, LPC, RN/BSN) 2 + years Supervisory experience Effective Team building skills Staff Education and Development activities experience Patient Satisfaction activities experience Bilingual ability (Spanish/English), and sensitivity to culturally diverse populations are desirable Lived experience in mental health and or in substance use disorders, and in recovery 35 hours/week Salary/pay rate: $70,000 - $75,000/year Benefits include health coverage (medical, prescription, and dental), paid time off (vacation, holidays, and sick), a deferred compensation plan, and enrollment in the NJ State Pension System.