Reference #: 5000971408406Quality Improvement Specialist111 Elwyn Road, Elwyn, Pennsylvania 19063

　　POSITION SUMMARY: The Quality Improvement Coordinator conducts internal evaluations of services to ensure quality care which fulfills all regulatory, funding agency, and internal standards; performs assessments of all services and make recommendations for improvement in all aspects of service delivery; and develops and implements policies for assuring compliance with all fire, health, safetys and security regulations.DUTIES AND RESPONSIBILITIES:Conduct internal evaluations for the assigned Adult Behavioral Health programs including, but not limited to:Self-initiate Quality Improvement (QI) and Quality Assurance (QA) projects to aid in Elwyn's on-going commitment to the delivery of exceptional services as indicated through internal evaluationsConduct reviews/audits of program plans and related documents for compliance with professional quality and regulatory standardsConduct chart audits to ensure quality of services delivered to clients and compliance with Managed Care Organization (MCO) policies as well as to ensure compliance with licensing regulationsPresent chart audit findings or other relevant information to program leadership on a monthly basis, as a summary email, requesting in-person or virtual meetings based on findings, as neededCreate effective internal control procedures based on audit findingsReport Quality Improvement needs to the Director of QI based on internal evaluations, and chart audits, providing recommendations for process improvementEvaluate all aspects of programming and ensure all policies and procedures are followed and enforcedObtain and maintain current Certified Investigator (CI) training and credentialingComplete investigations of incidents, as assigned, with tasks including but not limited to interviewing complainant, witnesses, and targets; visit site for investigation inspections; review any collateral records as indicated; preserve all evidence and maintain appropriate chain of custody; author comprehensive report of all investigation findings; and facilitate investigation debriefing and wrap-up with program leadership and Human ResourcesDevelop, implement, and monitor plans of correction as assigned; assist the QI Director with building processes and systems to prevent recurrence of identified issuesParticipate in the development of policies and procedures regarding utilization management, facility safety, and fire safety, in cooperation with the Director of QI and program leadership, based on  standardsAttend Elwyn and community-based committees and sub-committees, as assigned, looking for opportunities for process and policy improvement for the programs supportedConduct interviews and surveys with individuals supported, their families/guardians, staff members, advocates, etc. to verify that quality services are being delivered, and the program is meeting customer needsProvide in-service trainings for all Adult Behavioral Health staff to support compliance, program development, and thorough understanding of all program regulationsAnswer all questions regarding forms, policies, and protocols in regards to the annual program plan writing, implementation, revision, and trainingMaintain records of all compliance documentation and survey results as required under policyMaintain confidential program staff credentialing files and training records at the program location, under lock and keyRun and review training reports using the Elwyn computer database to make sure staff are compliant and up to date on all required trainings based on program regulationsSupport registration and scheduling of Elwyn staff and other third-party support resources for Elwyn training (eLMS), in cooperation with Elwyn Learning & Staffing Development, and the Clinical Coordinator; provide reports of missed trainings to Director of QI and program leadership to ensure trainings re completed, to maintain compliance, and to maintain exceptional resident careDetermine, by a monthly review of the exclusion list database, if Elwyn employees are noted; conduct due diligence based on any employees found on the list (e.g. coordinate with Risk Management and Human Resources, meet with the employee)Review, update, and maintain a current file of all QI tools used as part of continuous quality improvement (CQI), including but not limited to tools for chart, medication audit, physical site, finance, and data auditsMaintain up-to-date knowledge of all regulations and MCO policies through participation in external training offerings and review of regulatory body communications, communicating changes to the program, and keeping all programming policies and procedures current; maintain a current file of all program regulatory standards and updatesMonitor program compliance with federal, state, local, and managed care organization's (MCO) regulations as applicable, reporting any deficiencies to the DirectorCompare treatment notes to billing records, on a monthly basis at minimum, to verify time spent on each case for billing to payersEnter information concerning incidents in the current incident management system for reporting and analysis purposesPerform cardiopulmonary resuscitation (CPR), first aid, and crisis intervention using agency-trained protocolsPerform other duties as assignedIMMEDIATE SUPERVISOR: Director of Quality ImprovementDIRECT REPORTS: NoneCONTACTS:  Elwyn clients and staff, families/guardians; county and state agency regulators, representatives and vendors, federal, state, regional, county and local agency personnel and visitors.EDUCATION/EXPERIENCE/SKILLS REQUIREMENTS:High school diploma or graduate equivalency diploma (GED) with five (5) years' experience in human service or healthcare administration OR associate degree in human services, healthcare administration, nursing, social work, psychology, or other related field with a minimum of three (3) years in human services or healthcare administration; bachelor's degree with three (3) years in human services or healthcare administration preferred, Masters in Social Work (MSW), highly desiredExperience in the area of healthcare compliance preferredCurrent Pennsylvania Certified Investigator certification preferredDemonstrated ability to work effectively as part of a teamAbility to work in a fast-paced environment and manage and prioritize multiple, often competing, prioritiesDemonstrated strong attention to detailDemonstrated strong time management and organizational skillsDemonstrated excellent judgment with the ability to independently solve problems and make decisions with little or no need for direct supervisionDemonstrated ability to anticipate future needed changes or identify problem areas and take effective actionsMust be able to perform CPR, first aid, and crisis intervention using agency-trained protocolsDemonstrated intermediate experience with Microsoft Office applications, including Word, Excel, Outlook, and PowerPoint; report-writer experience preferredExperience in the use of electronic databases including but not limited to National Provider Identifier (NPI), learning management systems, Human Resources Information Systems (HRIS), and the county billing systemKnowledge of Electronic Health Record (EHR) / Electronic Medical Record (EMR) preferredMust have current, valid driver's license in state of residence, three (3) years driving experience in the United States, and acceptable driving recordPHYSICAL DEMANDS/ENVIRONMENTAL PROFILE: See Physic