Behavioral Health Quality Improvement Manager - 251107

Behavioral Health Quality Improvement Manager

Schedule: Full-Time

Shift: Days (8:00 AM – 4:30 PM)

Overview

The Behavioral Health Quality Improvement Manager supports the development, implementation, and oversight of quality improvement initiatives across inpatient and outpatient behavioral health services. This role focuses on regulatory compliance, incident investigation, performance improvement, and data-driven quality initiatives to enhance patient outcomes and maintain accreditation standards.

Key Responsibilities

• Support the design, implementation, and oversight of quality improvement programs across behavioral health services.
• Conduct thorough Root Cause Analyses (RCAs) for reportable incidents in collaboration with the Risk Management team, ensuring appropriate documentation and follow-up actions.
• Partner with program leadership to develop, implement, and track corrective action plans through completion.
• Maintain compliance with applicable regulatory and accreditation standards including state, federal, and accrediting body requirements.
• Align behavioral health quality initiatives with broader organizational strategic and performance goals.
• Oversee quality data collection and reporting processes while collaborating with Information Technology to ensure accuracy and timeliness of metrics.
• Implement and manage routine audits including:
• Medical record documentation reviews
• Environment of care inspections
• Compliance-focused evaluations in inpatient and emergency behavioral health settings
• Monitor inpatient psychiatric core measures, develop performance improvement plans, and provide education to staff to support clinical outcomes and regulatory compliance.
• Lead sustainable quality improvement initiatives by engaging leadership, frontline staff, and patients/families to identify priority areas and drive measurable improvements.
• Serve as project lead for statewide behavioral health collaborative initiatives, including suicide prevention and behavioral health data transparency programs.
• Conduct proactive risk assessments to identify operational vulnerabilities and implement mitigation strategies.
• Coordinate and complete treatment-over-objection processes for inpatient behavioral health units in accordance with regulatory guidelines.
• Contribute to departmental performance improvement initiatives and special projects as assigned.

Required Qualifications

• Master’s degree in Social Work, Psychology, Mental Health Counseling, Nursing, or a related field.
• Applicable professional license if required by discipline.
• Minimum of 3 years of experience in behavioral health quality or regulatory roles including:
• Medical record review
• Incident management and regulatory reporting
• Quality data analysis
• Performance improvement initiatives
• Survey readiness activities
• Experience working in licensed inpatient and/or outpatient behavioral health settings.

Preferred Experience

• Experience with behavioral health regulatory reporting and incident management.
• Knowledge of state oversight agencies and behavioral health reporting standards.
• Experience monitoring and improving behavioral health quality metrics and core measures.
• Strong data analysis and quality improvement project leadership experience.
• Experience across both inpatient and outpatient behavioral health environments.

Additional Information

• Full-time administrative role with standard daytime hours.
• Opportunity to lead impactful quality initiatives that improve behavioral health outcomes and regulatory compliance.