Quality Assurance/Quality Improvement Manager

UPDATED: 09/20/23
EMCMHC TITLE: Quality Assurance/Quality GRADE: Non-Exempt

Improvement Manager M-F, 0800-1700
Wage $60-$70k DOE

UNIT 0F SERVICE: Administration LOCATION: Miles City, Montana

EMPLOYEE
SIGNATURE: __________________________

I have read and received a copy of the job
description and agree that I can perform the
functions of the job with or without
accommodations.

JOB DESCRIPTION: Quality Assurance/Quality Improvement Manager: Ensure EMCMHC continual quality

improvement plan is maintained, updated and followed to ensure service and operational
objectives are achieved, in compliance with state, federal and local laws and rule.

RESPONSIBLE TO: Chief Executive Officer

SPECIFIC RESPONSIBILITIES:
Clinical Quality:

Works with EMCMHC’s Clinical QA/Evaluator and clinical staff and office managers to:
1. Interprets and implements quality assurance standards
2. Collaborates on manuals to include: Clinical, Program, Quality Assurance and Leadership
3. Provides monitoring for preventive and corrective actions, includes ability to recommend disciplinary action
4. Identifies training needs and organizes training interventions to meet quality standards
5. Monitors risk management activities
6. Reviews client grievances and complaints
7. Supports and monitors outcome measures model
8. Reviews client incident reports and recommends procedural and/or clinical policy changes

Audits/Surveys:

1. Conducts and/or oversees agency and program audits: DPHHS; SURS; Division of Quality Assurance; VA
2. Coordinates and supports on-site service audits conducted by external providers
3. Prepares reports for Leadership to communicate outcomes of quality activities and develops response for

formal audits
4. Evaluates audit findings and work with team members to implement appropriate corrective actions
5. Collaborates with Leadership regarding audit processes and results
6. Initiates, analyzes and prepares report of client surveys
7. Completes annual QA/UR report

ARMS/Regulatory Requirements:

1. Assures the EMCMHC’s compliance with the ARMS in all programs to include documentation that supports
appropriate billing

2. Assures ongoing compliance with quality and industry regulatory requirements

3. Monitor the Administrative Rules of Montana. May train leadership and/or employees accordingly
4. Creates policies and procedures that meet state and federal legal requirements
5. Reports issues pertaining to ARM/Regulatory to Leadership

Data Management:

1. Completes necessary reports and assessments in a timely manner in accordance with EMCMHC policy
2. Assists in the use of data analytics for information-powered organizational decision-making in regards to

processes and infrastructure

Confidentiality Regulations:
1. Conducts monitoring and investigates HIPAA violations

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2. Report issues pertaining to HIPAA to Leadership
3. Completes necessary actions for correction of HIPAA concerns, includes ability to recommend disciplinary

action

Training/Education:
1. Provides consultation and education services to outside agencies and the public as assigned

2. May represent the EMCMHC in giving comments to the ARMs hearings
3. Provides new hire orientation training on overall EMCMHC guidelines and HIPAA/ethics
4. Conducts HIPAA training upon request with ongoing awareness of HIPAA policies and procedures
5. Supports leadership in identifying culturally appropriate, trauma informed evidence based practices for

programs with additional guidance to implementation of those training models and monitoring for fidelity to
the model.

Will attend Clinical Directors/Incident Review Committee
Will attend Senior Leadership, Supervisors or other meetings as appropriate and assigned

Must have valid driver’s license, personal vehicle, and valid vehicle insurance will be traveling
Other duties as needed

1. Working Conditions
The majority of work is performed in a normal office environment where there is typically little or no risk

of injury. Travel for EMCMHC infrastructure (inspection), continuity of programming, QA/QI issues,
training, meetings, conferences, and other activities is required. Attendance is essential for this
position. Travel to all EMCMHC offices is required.

2. Knowledge, Skills and Abilities
a. Required is knowledge of concepts, theories, principles, practices and methods of psychology and

the ability to apply this knowledge to find unique and unprecedented solutions to client’s
psychological problems. Also required is knowledge of therapies, psychological assessment, and
the provision of psychological consultation and education. Must have good organizational and
managerial experience.
Thorough knowledge of the field of mental health and of the principles of delivery of mental health
services; thorough knowledge of community resources useful in the treatment and prevention of
emotional maladjustment.

Thorough knowledge of theory and practice in the field of specialization at a level appropriate for the
training and experience required, thorough knowledge of the principles of community organization.

Thorough knowledge of principles and methods of supervision and in-service training, and the ability
to supervise others. Thorough knowledge of the scope and activities of public and private health
and welfare agencies.

Ability to give in-service training; to secure professional, psychological or social work data and to
record such data systematically; to interpret and evaluate the data and develop recommendations;
and to write clear and accurate reports.

B. Management and Supervision of Others
None.

C. Supervision Received
This position is a member of EMCMHC’s Administration team and reports directly to the CEO.

Assignments are broadly stated in terms of objectives to be met. The employee is responsible for
planning and organizing the details of the work, deciding upon the methods to use to produce the
desired result, making proper interpretations, acting as the final authority, and held accountable for the
adequacy of the work produced.

D. Physical Demands
Must have satisfactory health, stamina and strength as the position necessitates frequent walking,
sitting, and lifting. Vision and hearing must be possessed to efficiently monitor clients. Climbing,

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stooping, kneeling, crouching, standing, walking, balancing, lifting 30lbs, typing, grasping, talking,
pushing, pulling, reaching, seeing, hearing, repetitive motions, subject to environmental conditions
internal and external cold and hot. Close visual acuity (i.e., computer screen) and visual acuity to
operate motor vehicle. Must be willing and able to assist in protecting clients from harming themselves
and/or others in emergency situations.

Quality Assurance Qualifications / Skills:

• Process improvement

• Analyzing information

• Strategic planning

• Verbal communication

• Informing others

• Quality engineering

• Emphasizing excellence

• Attention to detail

• Thoroughness

• Dealing with complexity

Education and Experience Requirements:

• BA or BS in appropriate discipline

• Experience with Continual QI/QA measuring and testing

• Working knowledge of quality system requirements

• Experience with MS Word, Excel, Project Management, and Analytics software

Application Process:

Applicants may apply online at www.emcmhc.org by filling out EMCMHC’s employment application and background

check. In addition to the required application documents, resumes may be submitted as well via email to

akurtz@emcmhc.org or via fax to: 406-234-0235 (Attn: Andrea). No phone calls please.

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