Manager Quality

SCCMHA JOB VACANCY ANNOUNCEMENT CLASSIFICATION: Manager of Quality & Medical Records Pay Range: $82,899.44 - $107,371.73 annually POSITION SUMMARY: The Manager of Quality & Medical Records provides strategic leadership, departmental oversight, and direction for SCCMHA's Quality and Medical Records Departments. This position is responsible for ensuring compliance with all federal and state regulatory requirements, leading agency wide quality improvement initiatives, overseeing medical records operations, and serving as a key advisor to the Chief Information Officer / Chief Quality & Compliance Officer. This position has independent authority to make operational decisions within the Quality and Medical Records Departments, including approval of workflows, reporting methodologies, and compliance actions. This position functions with significant independence, exercising broad discretion in decision making, resource allocation, and operational management. The Manager develops departmental strategy in collaboration with the CIOCQCO and is responsible for translating strategic priorities into operational plans, developing departmental strategy, establishes performance expectations, and ensures alignment with SCCMHA's mission, accreditation standards, and statewide reporting requirements. The Manager serves as a senior member of the Business Intelligence (BI) and Quality Teams, with authority to implement process improvements, approve departmental procedures, and direct cross functional teams. The Manager is a Primary Member of the BI Reporting Team and a core member of SCCMHA's Quality Governance Council, responsible for high level reporting, data integrity oversight, and ensuring compliance with MDHHS, MSHN, CARF, and other regulatory bodies. Serves as a key leader in agency wide compliance, accreditation readiness, and performance improvement initiatives. This position will be knowledgeable about and actively support culturally competent recovery-based practices; person centered planning as a shared decision-making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid persons served in the recovery process. ESSENTIAL DUTIES AND RESPONSIBLITIES: Strategic Leadership & Departmental Oversight 1. Provides strategic direction for the Quality and Medical Records Departments, including long range planning, resource allocation, staffing, and performance management. 2. Establishes departmental goals, KPIs, and operational standards; monitors progress and adjusts strategy as needed. 3. Develops and approves departmental policies, procedures, workflows, and documentation standards. 4. Serves as the agency's authority on quality improvement methodology, medical records compliance, and data integrity. 5. Independently resolves complex operational, compliance, and reporting issues with minimal oversight. 6. Evaluates departmental performance through dashboards, KPIs, and audit findings; implements corrective actions without requiring supervisory approval. 7. Authorizes changes to departmental workflows, documentation standards, and reporting structures. Quality Management & Regulatory Reporting 1. Responsible for the operations of the Quality Improvement Program. 2. Leads all Quality Improvement Projects, ensuring alignment with organizational priorities and regulatory expectations. 3. Oversees development of the Annual Quality Report & Plan. 4. Directs all Critical Incident Reporting functions, including compliance oversight, trend analysis, and reporting to MSHN and MDHHS. 5. Chairs and directs the Quality Governance Council, establishing priorities, approving project scopes, and ensuring alignment with agency strategic goals. 6. Oversees customer satisfaction survey design, distribution, analysis, and reporting. 7. Ensures compliance with all MDHHS quality data reporting requirements, including BH TEDS, MMBPIS, REMI submissions, and exception management. 8. Serves as the final reviewer for all quality submissions prior to executive approval. Medical Records Administration 1. Provides oversight of Medical Records operations, including release of information, record maintenance, archiving, and confidentiality compliance. 2. Ensures adherence to HIPAA, 42 CFR Part 2, Michigan Mental Health Code, and SCCMHA policies. 3. Approves complex or sensitive disclosures and resolves high risk confidentiality issues. 4. Ensures medical records staff maintain accurate logs, documentation, and record integrity. 5. Oversees internal audits of persons served records and ensures corrective actions are implemented. 6. Develops and enforces agency wide standards for documentation integrity and record retention. Business Intelligence & Data Governance 1. Serves as a senior BI leader responsible for data integrity, reporting standards, and enterprise reporting. 2. Assists with the development and maintenance of PowerBI dashboards, SSRS reports, pivot tables, and the BI Report Dictionary. 3. Provides high level data analysis for executive leadership, Board committees, and external partners. 4. Ensures compliance with all security and privacy requirements related to BI systems and reporting. 5. Acts as backup to the CIO on MSHN's IT Council and other regional/statewide committees. Process Improvement & Organizational Development 1. Leads agency wide process improvement initiatives using Rapid Cycle Quality Improvement methodologies. 2. Develops and delivers training for staff and network providers on quality & process improvement, data reporting, and compliance. 3. Provides consultation to leadership on performance indicators, trend analysis, and risk mitigation. 4. Oversees implementation of new quality reporting requirements and ensures EMR updates are completed. 5. Leads cross departmental process redesign efforts that impact clinical, administrative, and operational workflows. 6. Approves quality training curricula and ensures alignment with accreditation and regulatory expectations. Cross Functional Leadership 1. Collaborates with Compliance, IT, BI, Clinical, and Administrative teams to ensure alignment of quality and medical records functions. 2. Represents SCCMHA on regional and statewide committees, workgroups, and accreditation activities. 3. Serves as a senior advisor to the CIO/CQCO on quality, compliance, and data governance matters. 4. Serves as the agency's senior advisor on quality and medical records matters during audits, investigations, and accreditation reviews. INCIDENTAL DUTIES AND RESPONSIBILITES: 1. Assists the CIO/CQCO with policy development, strategic planning, and organizational initiatives. 2. Presents quality and medical records reports to SCCMHA Board committees, Citizens' Advisory Committee, and external audiences. 3. Attends required trainings, conferences, and professional development activities. 4. Attends meetings both in-person and remotely; presents to groups, facilitates meetings, creates agendas, maintains minutes, and performs needed project management tasks. 5. Attends meetings, seminars, workshops, and community events related to the public mental health mission and training sessions to maintain or upgrade current knowledge and skills required by this position and to maintain professional proficiency. 6. Provides executive level briefings to the CIO/CQCO and other leaders on departmental performance, risks, and strategic priorities. 7. May be required to commute to other SCCMHA facilities and business partners and vendor locations, when necessary, to investigate and resolve problems, implement new systems, train staff, etc. 8. May represent SCCMHA on state or regional committees and workgroups. 9. May serve as a member of various community committees, which promote the general goals of SCCMHA. 10. Must react productively and positively to change and handle other essential tasks as assigned. 11. Reads journals, periodicals, and research subjects on the Internet to increase job related knowledge and further professional and talent advancement. 12. Serves in a team setting approach by backing up other department personnel in their duties when needed. 13. Works closely with and coordinates efforts with all other agency staff and leadership as needed. 14. Works closely with and coordinates efforts with all Quality, Compliance, Business Intelligence, and Information Technology staff. 15. Provides executive level consultation to Directors and Supervisors regarding quality metrics, incident trends, and compliance risks. 16. Performs all other duties as assigned by the CIO/CQCO. (The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all duties and responsibilities required of personnel so classified.) REPORTING RELATIONSHIPS: Reports to: Chief Information Officer/Chief Quality and Compliance Officer Supervises: Quality Projects & Reporting Coordinator, Quality Improvement Program Coordinator, Quality Projects & Reporting Specialist, Typist Clerk - Medical Records WORKING CONDITIONS/ENVIRONMENT: 1. Daily exposure in all other department areas while working with staff at their workstation locations. 2. It is not unusual to work varied and extra hours to complete assignments to meet deadlines. 3. Occasional exposure to persons served with potential for disruptive, aggressive behavior and communicable diseases. 4. Occasionally drives personal automobile on agency business to offsite facilities or meetings, sometimes in bad weather. 5. Works at workstation using keyboard and viewing computer screen for long periods. 6. Works in typical professional office environment with pressures of time constraints, multiple projects, priorities, and numerous interruptions from telephone calls and walk-ins. 7. May be required to respond to urgent quality or medical records issues outside of standard business hours.