Responsibilities Located on 20 acres of rolling hills in a rural setting, about 45 minutes from Nashville, Tennessee, Oak Plains Academy offers psychiatric residential treatment services to children and adolescents ages 7–17, struggling with emotional and behavioral issues. The Oak Plains Academy campus features a full-size gymnasium, separate academic building, and four dormitories. Our wooded campus provides an excellent opportunity for outdoor recreational activities such as fishing, hiking, softball and basketball. If you would like to know more about the Director of Performance Improvement position, please email Erin.Young@UHSINC.com Position Summary We are seeking a Director of Performance Improvement who is responsible for coordinating and monitoring the facility-wide quality management assessment and quality performance improvement program, the Health Information Management Department including the management and maintenance of all patient medical records information, ensuring the facility’s programs are in compliance with all regulatory agencies, Joint Commission, CMS, and all other state and federal agencies. The Director of Performance Improvement is responsible for leading improvement of clinical outcomes through program evaluation and performance improvement functions including implementing tools used for programs and service evaluation, and organizing data collection and information analysis. Summary of Responsibilities Coordination of the facility-wide Performance Improvement Program ensuring the facility is in compliance with The Joint Commission and other regulatory agencies standards. Facilitation of the medical staff components of the program in conjunction with the Chief Medical Officer. Planning and chairing the PI function and reporting findings and activities to the Medical Executive Committee and the Board of Governers. Assistance provided to managers and leadership in establishing best practices based on research and data analysis. Promoting, planning, designing, coordinating and evaluating training and educational activities for all staff. Facilitates regulatory surveys to include facility readiness, training and resolutions of findings. Works with the risk department to ensure the implementation of organization-wide quality improvement activities. Maintains Health Care reporting system; ensuring data entry is timely and error free. Manages and oversees medical records department ensuring patient charts are complete and deficiencies addressed. Conducts medical record audits for compliance with regulatory requirements; analyzes audit results for trends and reports findings to Risk Manager. Maintains department files to facilitate rapid, efficient retrieval of documents and kept in a manner compliant with regulatory agency requirements. Respond quickly and proactively to performance indicators and data, resulting in higher quality staff and superior patient care. Prepare for and conduct the monthly Quality Council meeting. Assure the continuity of all business conducted is captured and concluded from month to month. Assist leadership in developing their role in performance improvement and participation on this committee. Respond to Quality of Care concerns from outside agencies as appropriate. Collect and submit all externally submitted performance measures. Provide on-going training for leadership and staff in the area of Quality and Performance Improvement and Corporate Compliance. Serves on facility committees as requested such as Utilization Review, Peer Review, Patient Safety Council, Pharmacy & Therapeutics, EOC/Safety, Infection Control, MEC and Governing Board. Collaborates with leadership to meet customer service and clinical quality outcomes for the customer service. Participate in the development and implementation of customer service and patient relations initiatives related to the facility’s mission and goals. Benefit Highlights • Challenging and rewarding work environment • Competitive Compensation & Generous Paid Time Off • Excellent Medical, Dental, Vision and Prescription Drug Plans • 401(K) with company match and discounted stock plan • SoFi Student Loan Refinancing Program • Career development opportunities within UHS and its 300+ Subsidiaries! About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $14.3 billion in 2023. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 96,700 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com Qualifications QUALIFICATIONS: Bachelor's degree required in Healthcare related program or information management 3 - 5 years’ experience in quality and risk management, improving organizational performance within an behaviroal health or psychiatric treatment setting and exceptional data analysis skills. Certification accreditation as a medical record professional, Registered Health Information Technologist (RHIT) or Registered Health Information Administrator (RHIA), as determined by the American Health Information Management Association (AHIMA). Expert level of proficiency in Microsoft Office, including Excel, PowerPoint, and WORD are required. A strong knowledge of JOINT COMMISSION, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities. Current drivers license in good standing. 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. Avoid and Report Recruitment Scams At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.