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