E00597 – Quality/Clinical Surveyor
Position Overview: Under the supervision the Senior Quality Assurance Strategist and in collaboration with the Regulatory Readiness Team, the Quality/Clinical Surveyor will conduct routine surveys of all RCA facilities and provide organizational leadership with post survey reporting and recommendations for improvement. This position will be responsible to maintain a schedule of internal surveys in advance of external annual surveys, to ensure proactive review and ongoing improvements as it relates to service delivery, documentation, supervision expectations, and quality monitoring processes.
Daily Responsibilities Include:
- Work collaboratively within the Regulatory Readiness Team
- Apply systems analysis and inductive reasoning to determine the degree of compliance with internal and external expectations, and service delivery systems and protocols
- Conduct on site reviews prior to survey and post site openings
- Medical Records Documentation
- Environment of Care Walk Throughs
- Review of Supervision Logs
- Review of HR files
- Review of Quality Committee agendas, minutes, PI plans, and data
- Review of Policy and Procedure Manuals
- Review of Site Specific Protocol Manuals
- Observation of site Processes (Treatment, FLASH, case conceptualizations, etc)
- In person review of facility activities: rounds, group sessions, psychoeducational sessions, etc.
- Engagement of healthcare staff in interactive dialogues on compliance status and expectations
- Complete a detailed exit briefing with site leadership to include areas of strength and areas for improvement. Exit would include but not be limited to:
- Citations for correction (providing source of citation)
- Recommendations for Improvement
- Suggestions for citations and recommendations for improvement, considering cost effective and efficient solutions
- Engages leadership to collaborate on solutions
- Complete a detailed post survey report inclusive of the following
- direct areas of citation with source of citation
- direct examples of citations,
- data analytics
- areas of strength
- system and/or process vulnerabilities
- analysis of level of risk
- recommendations for improvement
- suggestions and/or supports to utilize in performance improvement plan development
- Effectively engage and communicate process, expectations, findings, and reporting to organizational leadership in a manner that is collaborative and constructive
- Effectively observe health care site and operations in a manner that is not disruptive to treatment setting, staff and processes
Education and Experience:
- Masters degree in healthcare administration, psychology, social work, and/or a human services related field
- Independently licensed (LPC, LCSW, LCADC, etc).
- At minimum 5 years experience healthcare and/or quality management
- Understanding of systems of quality measurement/management and evidence based practices (American Society of Addiction Medicine, Substance Abuse and Mental Health Services Administration, Healthcare Effectiveness Data Information Set, National Committee for Quality Assurance, National Institute on Drug Abuse, National Alliance on Mental Illness)
- Understanding of state regulations and licensing board requirements and external survey process
- Understanding of Joint Commission Accreditation and survey process
- Understanding of Risk Management best practices as governed by the American Hospital Association, American Society for healthcare risk management
- Previous experience implementing systems and process to include organizational change management
- Understanding of managed care to include commercial insurance and CMS governance (Medicaid/Medicare)
- Experience working with and developing solutions within electronic health records
- Proficiency in Microsoft Office products (Office, Excel, Project)
- Excellent organizational skills required
Travel: 65% travel is required which includes local, out-of-the-area, and overnight travel.
Integrity: Upholds personal and professional ethics and values, considering the values of the organization and respecting the culture, beliefs, and abilities of individuals.
Confidentiality: upholds organizational, patient, and employee confidentiality at all times.
Customer Service: Demonstrates concern for meeting internal and external customers’ needs in a manner that provides satisfaction for the customer within the resources that can be made available.
Impact and Influence: Works effectively with and through others including those whom there is no formal authority over.
Communication: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.
Work Environment: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The noise level in the work environment is usually moderate.
Physical Demands: The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, or kneel. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.
Travel: Limited travel required, some out-of-the-area and overnight travel for organization-wide meetings.
Organization: Time Management: Determinates the appropriate allocation of time. Task Management: Balances conflicting priorities in order to manage workflow, ensure the completion of essential projects, and meet critical deadlines.
Judgment: Exhibits sound judgment and the ability to make reasonable decisions in the absence of direction; swiftly refers problems/issues to the appropriate person(s) when necessary; works effectively without constant and direct supervision or guidance.
Technical/Computer Skills: Displays proficiency using standard office equipment. Demonstrates advanced proficiency by quickly adapting to new technology and easily acquiring new technical skills