Clinical Quality Specialist - Behavioral Health

The Clinical Quality Specialist serves as the system’s behavioral health subject matter expert for quality, patient safety, accreditation, and regulatory compliance. This role supports the Behavioral Health COE by standardizing quality practices across all behavioral health locations, maintaining continuous survey readiness, and using data to drive measurable improvement in patient outcomes, safety, and experience. The specialist partners with facility quality leaders, behavioral health operational leaders, and medical staff to align local efforts with system quality goals and COE strategy.

• Keep all behavioral health sites ready for CMS, accrediting organization and state surveys, including mock surveys and on-site survey support.


• Lead corrective action plans from surveys, complaints and identified performance gaps.


• Support safety event review and root cause analysis. Lead suicide and ligature risk reduction efforts.


• Standardize documentation audits across sites, including treatment plans, psychiatric evaluations, suicide risk screening and restraint/seclusion.


• Submit required quality data, including CMS inpatient psychiatric (IPFQR) and state reporting.


• Build and maintain a behavioral health quality dashboard, and present results to leaders and committees.


• Lead improvement projects, and provide quality and regulatory education to staff and providers.

Qualifications 

• Bachelor's in Nursing or related clinical degree


• Active license in Indiana or multistate, in the corresponding clinical capacity 
  
  
  
  • Active, unencumbered RN, LCSW, LMHC, or LCAC license (or equivalent behavioral health license) preferred.
  
  
  
  


• Behavioral health experience