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Director Of Quality Assurance

Promises Behavioral Health

This is a Contract position in Wimberley, TX posted August 6, 2021.

Position Summary

The Director of Quality Assurance manages the facility Compliance Program by assisting the Group CEO with the initiatives designed to adhere to the standards, regulations and requirements issued by accreditation organizations and state/federal agencies. The role also collaborates with the field and Legal department in responding to escalated medical records requests made to the Company. 


Primary Duties and Responsibilities


  • Manages and coordinates, with assistance, key components of the Compliance Program that are designed to meet the requirements or recommendations of Federal and State regulatory agencies.
  • Supports the field compliance team in managing the day-to-day operations of the enterprise-wide Compliance Program, including assisting with the documentation needed to accompany state licensure applications and the voluntary accreditation process.
  • Lead the Quality Assurance and Performance Improvement Committee including meeting facilitation, Quality improvement initiatives and data monitoring
  • Lead Safety & risk mitigation efforts for the facility in partnership with the corporate legal, risk and compliance departments.
  • Monitor facility compliance with DSHS licensing and TJC accreditation requirements.
  • Work closely with Department leadership to insure compliance with necessary standards.
  • Creates reports for Compliance meetings.
  • Develops and maintains critical organizational systems designed to meet deadlines issued by regulatory bodies, organizes key policies and procedures and responds to escalated medical record requests.
  • Interfaces with client satisfaction survey data to develop reports to be used in Performance Improvement initiatives throughout the organization.
  • Review medical records for completeness, assemble records into standard order, and file records in designated areas according to applicable alphabetic and numeric filing systems.
  • Review files and documents in clients’ electronic medical charts for accuracy.
  • Respond to requests for information from files according to established policies and procedures.
  • Respond to inquiries from Clinical staff pertaining to medical records. Comply with federal HIPAA regulations and practice policies for the privacy and security of client information; explain the law and our privacy policy to clients as needed; maintain appropriate documentation of access to medical records.



Knowledge, Skills, and Abilities


  • Thorough understanding of the importance of confidentiality and non-disclosure according to the general standards set forth by HIPAA.
  • Knowledge of basic data processing procedures.
  • Knowledge of medical record keeping principles and practices and electronic medical records preferred.
  • Knowledge of medical terminology, standard nomenclature and classification of diagnoses and operations preferred.
  • Strong verbal and written communication skills.
  • Advanced Excel skills including pivot tables and formulas.
  • Ability to create and maintain policy and procedure documentation.


Qualifications and Requirements



  • BS, BSN, or MA preferred.  
  • Must meet pre-employment and maintain all applicable state and job-related guidelines for background screening, fingerprinting, drug testing, health screening, DMV, Insurance, CPR/Basic First Aid and license/credential verifications.


  • Minimum of five (5) years of work experience in a compliance or quality assurance role.
  • Minimum 6 months medical records experience preferred.
  • Experience handling sensitive information with complete confidentiality.
  • Experience maintaining policy and procedure documentation.
  • Preferred experience with The Joint Commission surveys and accreditation


Physical Requirements

  • Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly.
  • Hearing: Able to hear average or normal conversations and receive ordinary information.
  • Repetitive motion: Frequent and regular use of the wrists, hands, and fingers to make small movements such as typing or picking up small objects. Normal fine and gross motor control of fingers and hands.
  • Seeing: Visual acuteness necessary to prepare or inspect documents or other materials. Ability to accurately view computer monitors.
  • Physical: Frequent sitting, standing and walking. Occasional lifting up to 25 lbs. Occasional kneeling, stooping, and bending at the waist.
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