Chief Quality Officer

Title: Chief Quality Officer

State Role Title:Health Care Compliance Manager

Hiring Range: Commensurate based on experience

Pay Band: 6

Agency: Dept Behavioral Health/Develop

Location:Western State Hospital

Agency Website: Type: General Public - G

Job Duties

Location: Western State Hospital
103 Valley Center Drive Staunton VA 24401.

Who We Are
Western State Hospital part of the Virginia Department of Behavioral Health and Developmental Services (DBHDS) has been a leader in psychiatric treatment since 1828. WSH is a 302-bed Joint Commission/CMS-accredited psychiatric facility located in the scenic Shenandoah Valley. Just 30 minutes from vibrant university towns our hospital serves adults with serious mental health needs and is nationally recognized for our Psychosocial Rehabilitation Learning programs.

WSH provides a modern clinical setting and a therapeutic environment for patients supported by highly qualified staff. Employees also enjoy the beauty and tranquility of the Shenandoah Valley with nearby cities such as Charlottesville and Harrisonburg offering dining entertainment and outdoor activities making Staunton an attractive place to live and work.

Position Overview
Western State Hospital is seeking a full time Chief Quality Officer to direct the overall administration management and supervision of the Quality Management program Safety and Risk HIM Patient Relations and Utilization Review Program; direct and coordinate the hospital efforts to meet The Joint Commission and Centers for Medicare and Medicaid Services (CMS) accreditation standards; manage hospital database (S/R); coordinate a Performance Improvement (PI) program which meets the requirements set forth by The Joint Commission and furthers hospital quality of care goals; and provide independent validation of the effectiveness of departmental performance and ensures remedial corrective actions are taken as directed.

Key Responsibilities
- Provide executive leadership and oversight for all departments reporting to this role ensuring regulatory compliance efficient operations and alignment with organizational priorities.
- Manage and direct the Quality Management (QM) and Performance Improvement (PI) programs including development of QAPI plans policies annual strategic priorities and regular reporting to leadership.
- Oversee Joint Commission readiness and accreditation efforts including mock surveys compliance committee coordination corrective action plans and ongoing monitoring of standards.
- Supervise key staff including the Assistant Quality Manager Risk Management Director Utilization Review team and administrative/clerical support ensuring effective performance coaching documentation and accountability.
- Lead risk management and safety oversight serving as tertiary backup for incident review coordinating sentinel event responses and ensuring compliance with environmental and patient safety standards.
- Direct Medicare Compliance activities including training policy updates exclusion list monitoring billing audits fraud/waste/abuse investigations and facilitation of the Medicare Compliance Committee.
- Facilitate and support Quality/Patient Safety Council operations including agenda preparation data tracking FMEA coordination trend analysis and followup on action plans.
- Serve as liaison for Human Rights Committees (LHRC/SHRC) coordinating policy updates ensuring compliance with human rights regulations responding to findings and representing the hospital as needed.
- Provide governance consultation and executivelevel problem solving including resource planning contract oversight data analysis committee participation and participation in AdministratoronCall (AOC) rotation.
- Promote effective communication and teamwork by modeling open respectful communication fostering collaboration across departments and supporting a culture of safety accountability and continuous improvement.

Benefits Includes
Health vision and dental insurance
Retirement with cash match
13 paid holidays
Paid time off (annual sick family/personal and community service)
Life insurance

Minimum Qualifications

- Experience in Joint Commission/CMS standards compliance programs required
- Prior work experience in data management and analysis; developing quality management plans and annual reports; writing policies and procedures; teaching and training skills chairing work groups committees or teams.
- Prior supervisory/ management experience

Additional Considerations

- Degree in clinical behavioral or public administration field.
- Experience directing/overseeing Quality Management /Performance improvement program
- Experience with performance improvement team understanding of high reliability organizations lean six sigma a plus.
- Bilingual
Veteran/veteran spouse

Special Instructions

You will be provided a confirmation of receipt when your application and/or résumé is submitted successfully. Please refer to Your Application in your account to check the status of your application for this position.

Application Requirements: Applications and résumés for this position are accepted electronically through the Commonwealth of Virginias Electronic Recruitment System only. Interview decisions will be based solely on the information provided in your electronic application and/or résumé. Please ensure you clearly and specifically detail all relevant work experience; we will not make assumptions about your qualifications.

Background Investigation: All applicants are subject to an extensive background investigation and a pre-employment drug screening. This investigation may include fingerprint checks (State Police FBI) local agency checks Department of Social Services/Child Protective Services checks employment verification and verification of education relevant to the position.

Under Virginia Code 37.2-314 and 37.2-408.1 the Department of Behavioral Health & Developmental Services (DBHDS) cannot employ or utilize as volunteers individuals convicted of specific (barrier) crimes or those with pending barrier charges.

Reasonable Accommodations: Reasonable accommodations are available to individuals with disabilities during the application and/or interview process in accordance with the Americans with Disabilities Act. If you require assistance or accommodation please notify Human Resources at during business hours (8:00 a.m. to 5:00 p.m.).

Equal Opportunity: The Commonwealth of Virginia is committed to conducting all aspects of human resource management without regard to race (or traits historically associated with race including hair texture hair type and protective hairstyles such as braids locks and twists) sex color national origin religion sexual orientation gender identity or expression age veteran status political affiliation disability genetic information and pregnancy childbirth or related medical conditions.* There shall be no retaliation against anyone making allegations of violations of this policy.

Veteran Preference: DBHDS is a Virginia Values Veterans (V3) certified employer and provides hiring preference to qualified veterans and service members. We strongly encourage veterans active members of the Virginia National Guard and U.S. Military Reserve members to apply to the state application and respond accordingly.

Contact Information

Name: Samantha Leep

Phone:

Email:

In support of the Commonwealths commitment to inclusion we are encouraging individuals with disabilities to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity applicants will need to provide their AHP Letter (formerly COD) provided by the Department for Aging & Rehabilitative Services (DARS) or the Department for the Blind & Vision Impaired (DBVI). Service-Connected Veterans are encouraged to answer Veteran status questions and submit their disability documentation if applicable to DARS/DBVI to get their AHP Letter. Requesting an AHP Letter can be found at AHP Letter or by calling DARS at .

Note: Applicants who received a Certificate of Disability from DARS or DBVI dated between April 1 2022- February 29 2024 can still use that COD as applicable documentation for the Alternative Hiring Process.