Clinical Quality Manager

Tompkins County Whole Health is seeking a Clinical Quality Manager to lead clinical quality improvement and utilization review activities across the Department’s licensed mental health and public health programs. 
This is a 35-hour-per-week position with a hire rate of $35.51 per hour and a working rate of $38.51 per hour after nine months. The Clinical Quality Manager reviews clinical records and service data to evaluate documentation quality, medical necessity, person-centered care, regulatory compliance, and Medicaid billing requirements.  This position coordinates external audits and program reviews, monitors changes in OMH, DOH, Medicaid, HIPAA, and other requirements, and translates those requirements into practical policies, workflows, documentation standards, and staff training. The role also leads cross-functional quality-improvement projects and develops recommendations and corrective-action plans to strengthen care and reduce organizational risk. 
The ideal candidate combines knowledge of clinical practice and healthcare regulation with strong analytical, communication, and project leadership skills. They should be comfortable fostering collaboration and quality improvement within a multidisciplinary team, working independently, interpreting complex requirements, communicating sensitive findings, and handling confidential information with sound judgment and integrity.

MINIMUM QUALIFICATIONS: 
1.) Masters Degree in Social Work, Mental Health Counseling, Psychology, Healthcare Administration, Nursing, or a related field AND two (2) years of related experience in healthcare, behavioral health, social services or insurance; OR 
2.) Bachelor’s Degree in Social Work, Mental Health Counseling, Psychology, Healthcare Administration, Nursing, or a related field AND four (4) years of related experience in healthcare, behavioral health, social services or insurance; OR
3.) Registered Nurse (RN) AND four (4) years of experience in healthcare, behavioral health, social services or insurance; OR 3. 4. An equivalent combination of training and experience as defined by the limits above.
SPECIAL REQUIREMENTS: 
Pre-Employment Screenings: Final appointment to this position is contingent upon successful completion of all required pre-employment screenings, which may include a criminal background check, Staff Exclusion List clearance, and any required OCFS check(s), as applicable to the position. Candidates must authorize and cooperate with these reviews as part of the hiring process.

DISTINGUISHING FEATURES OF THE CLASS: 
The Clinical Quality Manager is responsible for planning, administering, and evaluating Whole Health’s clinical quality and utilization review program across licensed Mental Health and Public Health services. The incumbent ensures clinical documentation, billing practices, and service delivery meet federal, state, and local regulatory requirements, including NYS Office of Mental Health (OMH), Department of Health (DOH), Medicaid, HIPAA and county policy standards. Work involves collaboration with clinical, administrative, fiscal, and compliance personnel to improve service quality, reduce audit risk, and promote adherence to evidence-based and person-centered care. 

Work is performed under the general supervision of the Quality Assurance and Improvement Coordinator, within Operational Support Services at Tompkins County Whole Health. The incumbent exercises high autonomy and independent judgement, interpreting broad, detailed and distinct sets of regulations as they are applied to clinical practice, documentation, and organizational processes. The position entails complex judgement to discern how quality care measures are being met, and includes initiation of new policies, practices, and processes to meet organizational goals. The incumbent leads cross-functional workgroups and clinical quality improvement projects; establishes project objectives and timelines, coordinates assignments, monitors implementation, resolves project-level issues, and evaluates results.

TYPICAL WORK ACTIVITIES: 

Develops and administers a systematic, risk-based utilization review process for Whole Health services, including establishing review priorities, selecting records and data for review, applying review criteria, documenting findings, and identifying matters requiring corrective action or additional leadership review. Independently reviews clinical records to determine whether documentation supports medical necessity, service appropriateness, person-centered care, state and federal regulatory compliance, and applicable Medicaid billing requirements. • Serves as the department’s subject-matter expert for clinical documentation quality and utilization review advising and collaborating with division leadership for all programs across Whole Health. To interpret requirements, identify risks, and improve practices. • Leads department preparation and coordination of external audits and program reviews. The incumbent organizes the supporting documentation, serves as the technical liaison with OMH, DOH, and other regulatory entities throughout the review and manages the response process. The incumbent’s findings and recommendations may affect clinical practice, client safety, Medicaid reimbursement, audit and recoupment exposure, corrective-action requirements, and the department’s continued compliance with program licensing standards. • Monitors changes in OMH, DOH, Medicaid, HIPAA, 42 CFR Part 2, and other applicable requirements; independently evaluates their operational impact; and recommends revisions to policies, workflows, clinical documentation standards, electronic health record forms, and staff training. • Leads or coordinates multidisciplinary quality-improvement initiatives related to identified clinical priorities, which may include suicide prevention, overdose prevention, trauma-informed care, client engagement, care transitions, and other departmental quality objectives. • Analyzes utilization review findings, service data, client outcomes, and compliance measures to identify systemic patterns, deficiencies, emerging risks, and improvement opportunities. • Develops and presents findings and evidence-based recommendations to program directors, clinical supervisors, quality committees, and department leadership. • Develops or recommends corrective-action and performance-improvement plans; establishes measures of success; monitors implementation; conducts follow-up reviews; and evaluates whether identified deficiencies have been resolved. • Designs and implements periodic satisfaction surveys, client interviews, and focus groups to gather client input and assess program outcomes. • Analyzes quantitative and qualitative client feedback and develops recommendations and action plans in response to identified themes, concerns, and improvement opportunities. • Designs, develops, delivers, and evaluates training related to clinical documentation, medical necessity, regulatory requirements, quality-of-care standards, and utilization review findings. • Assists onboarding new clinical staff, developing documentation skill sets and reviewing relevant policies, procedures, and regulations. • Provides technical assistance to program staff regarding documentation standards, quality care, and quality improvement practices. • 

KNOWLEDGE, SKILLS, ABILITIES AND PERSONAL CHARACTERISTICS: 

Thorough knowledge of OMH regulations, DOH regulations, Medicaid billing standards, and clinical documentation requirements for licensed clinical programs. • Comprehensive knowledge of evidence-based and evidence-informed behavioral health treatment approaches, including the principles of cognitive behavioral, motivational, family-centered, recovery-oriented, and trauma-informed practices. • • Working knowledge of public health programs and practices, prevention models, and population health strategies. Ability to translate complex regulatory and clinical requirements into policies, workflows, documentation standards, training, and measurable performance expectations. • • Strong analytical skills; ability to identify trends, deficiencies, and areas requiring corrective action. • Ability to prepare clear written reports and audit documentation. Thorough knowledge of utilization review, clinical quality management, healthcare auditing, and corrective-action processes. • • Ability to design, implement, and evaluate utilization review and clinical quality improvement programs. Ability to provide functional leadership and obtain cooperation from clinical professionals, supervisors, program directors, and multidisciplinary workgroups. • • Ability to communicate complex or potentially controversial findings to clinical and administrative leadership. Considerable interpersonal and communication skills are required to facilitate consensus, resolve disagreement, and obtain cooperation from directors, supervisors, clinicians, and multidisciplinary staff regarding clinical standards, documentation expectations, organizational risk, and process implementation. • The position requires extreme visual effort associated with intensive review of clinical records, regulations, audit documentation, reports, and data. The work requires advanced proficiency with electronic health records, clinical documentation forms and workflows, databases, spreadsheets, audit tools, and reporting systems. • The position entails fostering strong relationships with internal stakeholders across divisions and departments, guiding the implementation of policies and coordinating implementation across programs, divisions, and partner agencies. • Sound judgment and integrity in handling confidential and sensitive information in accordance with HIPAA, 42 CFR Part 2, and County policies. • The work involves frequent competing priorities, unannounced regulatory reviews, tight deadlines, and regular review of records involving trauma, mental illness, substance use, abuse, suicide risk, and other distressing circumstances.