Clinical Quality Manager

Description

 The Clinical Quality Manager partners with clinical and operational leaders across Haymarket Center’s continuum of care to identify performance gaps, facilitate improvement initiatives, strengthen compliance systems, and support sustainable change initiatives. This position oversees Haymarket’s quality management activities through the application of improvement science, data-informed decision making, change management strategies, regulatory compliance monitoring, and accreditation readiness. This position supervises two Quality Improvement Coaches and oversees agency processes related to record reviews, utilization management, performance improvement, licensing, accreditation, and regulatory compliance. This role serves as a trusted advisor, facilitator, and educator who helps staff translate quality and compliance requirements into practical processes that improve care delivery while maintaining fidelity to evidence-based treatment models.

PERFORMANCE EXPECTATIONS:

This position directly influences the quality of care provided to individuals seeking Haymarket services. By helping teams improve systems rather than simply identifying deficiencies, the Clinical Quality Manager will:

· Improve documentation quality and regulatory compliance. 

· Increase staff engagement with quality improvement activities. 

· Reduce recurring audit findings and corrective action plans. 

· Improve consistency in treatment planning and discharge planning processes. 

· Build the organization's capability to sustain changes over time.

· Instill principles of improvement science in Haymarket’s teams.

POSITION RESPONSIBILITIES

Quality Improvement Leadership

• Lead and      facilitate continuous quality improvement initiatives across behavioral      health, substance use disorder, and primary care programs using      improvement science methodologies and structured change management      approaches.
• Partner with      clinical and operational teams to identify quality, compliance, and      performance gaps and develop practical improvement strategies that      strengthen outcomes and service delivery.
• Coach leaders and      staff in the use of quality improvement tools, including Plan-Do-Study-Act      (PDSA) cycles, root cause analysis, workflow improvement, process mapping,      and performance measurement.
• Design, implement,      and monitor performance improvement projects aligned with strategic      priorities, regulatory requirements, and accreditation standards.
• Facilitate      interdisciplinary quality improvement teams and support implementation of      corrective action plans and sustained practice improvements.
• Monitor progress      toward quality goals and ensure follow-through on performance improvement      plans.

Quality Assurance and Compliance

• Conduct and      oversee record reviews for mental health, substance use disorder, and      primary care services to ensure compliance with applicable regulatory,      contractual, and accreditation requirements, including Illinois Rules 2060,      132, and 140, among others.
• Coordinate regular      record reviews, utilization reviews, and compliance audits in accordance      with agency policies and quality management processes.
• Monitor adherence      to policies, procedures, and established standards throughout treatment      programs and service areas. Support standardization of procedures across      teams. Assist with the development, revision, and implementation of agency      policies, procedures, and quality-related protocols.
• Analyze findings      and prepare reports identifying trends, opportunities for improvement,      areas of risk, and recommendations for corrective action.
• Collaborate with      program leaders to address identified deficiencies and monitor completion      of corrective action plans.
• Ensure program      compliance with applicable federal, state, payer, and accrediting body      requirements.
• Maintain ongoing      knowledge of regulations, standards, funding requirements, and best      practices impacting agency services. Help lead accreditation readiness      activities and support continuous compliance with applicable accreditation      standards.
• Assist in      preparation for licensing reviews, certification visits, audits, and      accreditation surveys. 

Licensing and Regulatory Oversight

• Ensure agency      licenses, certifications, and approvals remain current and in good      standing.
• Coordinate license      renewals, modifications, and applications for new program licenses as      needed.
• Interpret      regulatory requirements and provide guidance to leadership regarding      operational and clinical compliance expectations.

Staff Coaching and Change Management

• Serve as the link      between Haymarket trainings and day-to-day sustained implementation of      lessons learned during those trainings.
• Provide education      and consultation to clinical and operational teams on quality assurance,      regulatory compliance, documentation standards, and performance      improvement processes.
• Apply change      management principles to support successful implementation of new      processes and practices. Help staff understand the purpose behind quality      measures, documentation requirements, and operational processes.
• Foster a culture      of learning, accountability, innovation, and continuous quality      improvement throughout the organization.
• Regularly      communicate quality, compliance, accreditation, and performance      improvement findings to agency leadership.
• Maintain effective      working relationships with program managers, directors, external      reviewers, auditors, licensing representatives, and accreditation      surveyors.
• Keep the Director      of Quality Assurance informed of significant quality, compliance, risk,      and operational concerns.
• Supervise and      support two Quality Improvement Coaches and ensure a culture of empathy      among the Quality Team members and staff they support.

SUPERVISORY RESPONSIBILITIES:

Quality Improvement Coach (2)

Records Manager

Requirements

· Master’s degree in Human Services or related field; license preferred (LPC/LCPC).

· Certified Alcohol and Drug Counselor (CADC) or licensed by IDFPR with SUD experience 

· At least five (5) or more years of experience in the field of Human Services working in human services agency.

· Familiarity with the various funding agencies such as Illinois Department of Human Services, Divisions of Substance Use, Prevention, and Recovery and Mental Health.

· Familiarity with Illinois Department of Human Services rules, standards, and guidelines.

· Familiarity with CARF (Commission on Accreditation of Rehabilitation Facilities) standards. Will consider familiarity with standards of The Joint Commission.

· Excellent communication skills, 

· Strong interpersonal and problem-solving abilities

· Good writing skills

· Good analytical skills

· Knowledge of computers

· Ability to work independently

· Demonstrate ability to interpret regulatory rules, standards and guidelines