Director (OBH), Behavioral Health Quality Assurance

				Overview:

The OBH Director of Behavioral Health Quality Assurance is responsible for overseeing and advancing quality improvement, regulatory compliance, and risk management (NIMRS) across all behavioral health services for One Brooklyn Health System (OBH). This role ensures the delivery of safe, effective, and patient-centered care through data-driven performance improvement initiatives, robust quality assurance programs, and continuous monitoring of clinical outcomes. The Director serves as a strategic leader and subject matter expert in behavioral health quality, incident review and compliance standards.

Responsibilities:

* Quality Improvement & Assurance
* Develop, implement, and oversee the Behavioral Health Quality Assurance/Performance Improvement Program.
* Design and manage performance improvement initiatives based on outcome data, clinical indicators, and patient feedback.
* Lead root cause analysis, failure mode effects analysis (FMEA), and incident reviews to reduce risk and improve care.

* Regulatory & Compliance
* Ensure compliance with all federal, state, and accrediting bodies (e.g., Joint Commission, CMS, HIPAA, state mental health departments, and the Justice Center).
* Prepare for and manage external audits, surveys, and regulatory inspections.
* Maintain policies and procedures that align with current laws, regulations, and best practices.

* Incident Review Investigations
* Performs incident review investigations and reports findings to the appropriate investigating body.
* Collaborate with colleagues across the system to review, assess and submit the documentation and required documents.

* Data Analysis & Reporting
* Collect, analyze, and report data related to key performance indicators (KPIs), quality metrics, and clinical benchmarks.
* Present findings and improvement recommendations to executive leadership and board-level quality committees.

* Team Leadership & Collaboration
* Supervise quality staff and lead multidisciplinary quality improvement teams.
* Provide training and support to clinical and administrative staff on QA/QI processes.
* Foster a culture of accountability, transparency, and continuous improvement.

Qualifications:

Education:

* Master's degree in Nursing, Psychology, Social Work, Public Health, Healthcare Administration, or a related field required. 

Experience:

* Minimum of 7 years of progressive experience in behavioral health quality improvement, with at least 3 years in a leadership role.

Licenses, Certifications:

* RN, LCSW, LMFT, or relevant clinical license preferred. Certification in Healthcare Quality (CPHQ) strongly preferred.

Knowledge, Skills and Abilities:

* Deep knowledge of behavioral health systems, clinical care standards, and regulatory requirements.
* Strong leadership, communication, and organizational skills.
* Proficient in data analysis, performance measurement, and process improvement methodologies 
* Experience with electronic health records (EHRs) and quality reporting systems

 Physical Demands:

* Involves standing, walking, sitting, talking, hearing and bending. 
* May include some repetitive motions. 
* Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.

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The Brookdale Hospital Medical Center