Director of Regulatory & Quality Behavioral Health
Company: Universal Health Services, Inc.
Location: Auburn Hills
Posted on: February 25, 2021
Director of Regulatory & Quality Behavioral Health Director of
Regulatory & Quality Behavioral Health
- Executive, Behavioral Health - Counselor
- Havenwyck Hospital Job Description Responsibilities Havenwyck
Hospital is a Joint Commission-accredited and licensed psychiatric
hospital, overlooking Lake Galloway in Auburn Hills, Michigan. We
specialize in providing comprehensive, compassionate behavioral
health services to children, adolescents and adults. It is the
ultimate goal of our dedicated staff to build strength, confidence
and knowledge within each patient, in hopes that they may continue
learning and understanding their needs and practicing self-care for
the rest of their lives. Havenwyck Hospital UHS Benefits include:
- Challenging and rewarding work environment
- Competitive Compensation & Generous Paid Time Off
- Excellent Medical, Dental, Vision and Prescription Drug
- 401(K) with company match and discounted stock plan
- SoFi Student Loan Refinancing Program
- Career development opportunities within UHS and its 300+
- Tuition Assistance If you would like to learn more about the
position before applying, please contact Human Resources at
248-373-9200. What do our current employees value at Havenwyck
Hospital & UHS? An environment that puts patient care first. One of
the most rewarding aspects of working as an employee is providing
excellent care, comfort, and security to the patients and families
you treat, at their most vulnerable times. Supportive and
responsive leadership. You are never alone, as you are part of a
large network of peer nurses and nursing leaders that routinely
exchange ideas and review current topics within the industry.
Having the opportunity to grow, learn, and advance in your career.
There are very robust continuing education options and
opportunities for skills diversification and career advancement as
an employee with UHS. One of the nation's largest and most
respected providers of hospital and healthcare services, Universal
Health Services, Inc. has built an impressive record of achievement
and performance. Growing steadily since its inception into an
esteemed Fortune 500 corporation, our annual revenues were $10.77
billion in 2018. In 2020, UHS was again recognized as one of the
World's Most Admired Companies by Fortune; in 2019, ranked #293 on
the Fortune 500; and in 2017, listed #275 in Forbes inaugural
ranking of America's Top 500 Public Companies. Headquartered in
King of Prussia, PA, UHS has more than 87,000 employees and through
its subsidiaries operates 26 acute care hospitals, 327 behavioral
health facilities, 40 outpatient facilities and ambulatory care
access points, an insurance offering, a physician network and
various related services located in 37 U.S. states, Washington,
D.C., Puerto Rico and the United Kingdom. Havenwyck Hospital is
seeking a dynamic and talented--Director of Regulatory and Quality
to join our team of compassionate, dedicated professionals. The
Director of Regulatory and Quality-- is responsible for the
development, implementation, coordination, and aggregation of the
hospital wide Performance Improvement Plan. Additionally, the
individual is responsible to develop, implement and oversee all
regulatory compliance activities to ensure compliance with all The
Joint Commission, CMMS and State standards, rules and conditions of
participation. Duties include, but are not limited to:
- Collects, coordinates and maintains informational reports from
all departments and committees as outlined in the Performance
Improvement (PI) Plan.
- Provides expertise in responding to quality requirements of
external agencies, i.e. The Joint Commission. CMMS, etc.
- Coordinates and monitors the hospital wide PI Plan in order to
maintain compliance with The Joint Commission, CMMS, and other
- Evaluates and improves the systems, forms, procedures, methods,
and motions used in accomplishing all PI work.
- Assists Medical Staff in evaluating the quality of patient care
and in developing criteria and methods for such evaluation.
- Provides ongoing communication, resources, education, and
aggregated data/information to all department managers, related to
issues involving quality, safety, and survey readiness.
- Assist with annual evaluation (and revision if necessary) of
the PI Plan.
- Plans, develops, and presents in-services relevant to PI and
survey readiness as necessary.
- Responsible for the review, development, and implementation of
the department policies and procedures.
- Serves as a liaison between the medical staff, or committees
and the Health Information Management Department.
- Serves as the facility's Compliance Officer.
- Ensures the hospital's environment is safe, clean, and well
organized. Makes recommendations for resources and adequate space.
Submits requests for repairs and for required equipment. Conducts
quarterly safety rounds.
- Maintains knowledge and understanding of The Joint Commission
(CAMH, CAMBH) and CMMS Standards and strategies for compliance.
Acts as the facility liaison during the survey process including
other applicable state and federal regulatory agencies. Ensures
timely response and oversees development and implementation of any
required corrective actions. Assigns tasks as necessary to other
departmental managers to assist in overall regulatory
- Reviews and analyzes root causes, patterns, or trends in data
collection and informs applicable Facility management staff; helps
to identify and implement corrective action and performance
- Provides continuous support in the analysis of performance
improvement initiatives and re-establishing requirements which will
facilitate continuous improvement. Fosters the development and
tracking of performance indicators at the departmental level;
encourages a facility-wide team effort in meeting performance
- Assures that hiring, disciplinary actions and termination
procedures are conducted in accordance with hospital policies.
- Bachelor's degree in Human or Health Services field required.
MSN or advanced degree preferred.
- Valid licensure in the State of Michigan as a RN, NP, MSW, MA,
PhD in psychology, or PsyD required.
- At least five years clinical experience required in a related
- 3 - 5 years of management experience required.
- Relevant experience and demonstrated skill in data aggregation
and interpretation, analysis and process improvement required.
- Experience collecting and interpreting patient information
- Experience collecting and analyzing performance and incident
data at the medical staff and organizational level.
- Thorough knowledge of regulatory and accrediting agency
standards, rules and regulations (i.e., The Joint Commission, CMMS,
DHHS, etc.) required.
- Proficient in Microsoft Word, Excel and PowerPoint applications
- Employees must be in good standing (employment/corrective
action history, evaluation, etc.) to be considered for internal
transfers. EEO Statement All UHS subsidiaries are committed to
providing an environment of mutual respect where equal employment
opportunities are available to all applicants and teammates. UHS
subsidiaries are equal opportunity employers and as such, openly
support and fully commit to recruitment, selection, placement,
promotion and compensation of individuals without regard to race,
color, religion, age, sex (including pregnancy, gender identity,
and sexual orientation), genetic information, national origin,
disability status, protected veteran status or any other
characteristic protected by federal, state or local laws. We
believe that diversity and inclusion among our teammates is
critical to our success. Notice At UHS and all subsidiaries, our
Human Resources departments and recruiters are here to help
prospective candidates with matching skillset and experience with
the best possible career at UHS and our subsidiaries. We take pride
in creating a highly efficient and best in class candidate
experience. During the recruitment process, no recruiter or
employee will request financial or personal information (Social
Security Number, credit card or bank information, etc.) from you
via email. The recruiters will not email you from a public webmail
client like Hotmail, Gmail, Yahoo Mail etc. If you feel suspicious
of a job posting or job-related email, let us know by contacting us
at: https://uhs.alertline.com or 1-800-852-3449 UHS is a registered
trademark of UHS of Delaware, Inc., the management company for
Universal Health Services, Inc. and a wholly-owned subsidiary of
Universal Health Services, Inc. Universal Health Services, Inc. is
a holding company and operates through its subsidiaries including
its management company, UHS of Delaware, Inc. All healthcare and
management operations are conducted by subsidiaries of Universal
Health Services, Inc. To the extent any reference to "UHS or UHS
facilities" on this website including any statements, articles or
other publications contained herein relates to our healthcare or
management operations it is referring to Universal Health Services'
subsidiaries including UHS of Delaware. Further, the terms "we,"
"us," "our" or "the company" in such context similarly refer to the
operations of Universal Health Services' subsidiaries including UHS
of Delaware. Any employment referenced in this website is not with
Universal Health Services, Inc. but solely with one of its
subsidiaries including but not limited to UHS of Delaware, Inc.
--UHS is not accepting unsolicited assistance from search firms for
this employment opportunity. Please, no phone calls or emails. All
resumes submitted by search firms to any employee at UHS via-
email, the Internet or in any form and/or method without a valid
written search agreement in place for this position will be deemed
the sole property of UHS. No fee will be paid in the event the
candidate is hired by UHS as a result of the referral or through
other means. Are you interested in learning more about
opportunities with Havenwyck Hospital? Havenwyck Hospital is owned
and operated by a subsidiary of Universal Health Services, Inc.
(UHS), a King of Prussia, PA-based company, that is one of the
largest healthcare management companies in the nation.
UHS is a registered trademark of UHS of Delaware, Inc., the
management company for Universal Health Services, Inc. and a
wholly-owned subsidiary of Universal Health Services. Universal
Health Services, Inc. is a holding company and operates through its
subsidiaries including its management company, UHS of Delaware,
Inc. All healthcare and management operations are conducted by
subsidiaries of Universal Health Services, Inc. To the extent any
reference to "UHS" or "UHS facilities" on this website including
any statements, articles or other publications contained herein
relates to our healthcare or management operations it is referring
to Universal Health Services' subsidiaries including UHS of
Delaware. Further, the terms "we," "us," "our" or "the company" in
such context similarly refer to the operations of Universal Health
Services' subsidiaries including UHS of Delaware. Any employment
referenced in this website is not with Universal Health Services,
Inc. but solely with one of its subsidiaries including UHS of
Havenwyck Hospital is an Equal Opportunity Employer and as such,
openly supports and fully commits to recruitment, selection,
placement, promotion and compensation of all individuals without
regard to race, color, religion, age, sex (including pregnancy,
gender identity, and sexual orientation), genetic information,
national origin, disability status, protected veteran status or any
other characteristic protected by federal, state or local
Keywords: Universal Health Services, Inc., Detroit , Director of Regulatory & Quality Behavioral Health, Healthcare , Auburn Hills, Michigan
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