This position is responsible for continuous quality improvement by conducting and analyzing satisfaction surveys, Secret Shopper reports, Network Service Provider (NSP) monitoring, performance reports and corrective action plans. This position tracks Providers’ compliance with submission of contractually required reports, conducts monitorings, and generates reports to develop quality improvement initiatives that impact client care and systems management.

Required Education/Experience

  • Bachelor’s degree in Quality Assurance, Health Administration, or related field.
  • Strong knowledge of quality improvement processes, data analysis, and practices of collaborative quality improvement initiatives.
  • Two years’ experience providing quality oversight, preferably in the provision of mental health/substance abuse services.


Essential Job Functions

  • Quality Improvement – Identify and propose solutions for continuous process improvement at NSP and CFCHS levels. Maintain and update the agency’s Continuous Quality Improvement Plan and assist departments in identifying internal goals that support identified needs and the agency’s mission and vision.
  • Monitoring NSP and Corrective Action Plans (CAP) Tracking – Responsible for various aspects of the monitoring process, including, but not limited to designated monitoring tools, interviewing of staff and clients, following up with Corrective Action Plans. Review and analyze trends related to CAPs, present reports to peers and leadership.
  • Satisfaction Surveys – Coordinate processing of satisfaction surveys (CSS, PSS, and BSS) including reviewing questions and setup, tracking, trending, analysis, and reporting. Follow up with Providers, as needed.
  • Secret Shopper Program – Conduct calls to assess Provider’s customer service, information, access and referral, prepare reports, work with Providers identifying issues and implementing improvement interventions. Trend results and notify leadership of issues.

o Gather and evaluate region specific performance measure data for patterns and trends to determine barriers, needs, and opportunities for service improvement.

o Work with various CFCHS Departments in addressing Provider issues that impact Provider’s ability to meet the contractually required performance outcomes.

o Communicate with Providers and offer technical assistance and training as required.

  • Client Relations – Identify data trends and help identify initiatives to improve them.
  • Network Report Tracking System

o Develop a system to track all reports submitted by providers based on their contract Exhibit B.

o Report to management Providers’ compliance with report submission.

o Work with NSP to address all issues related to report compliance.

  • Emergency Preparedness – Perform duties as assigned, which may include deployment during a disaster.
  • It is an essential function of this position to be kind, respectful, and thoughtful to others while you are performing the duties that make up this job.
  • Other duties as assigned.


Required Knowledge, Skills & Abilities

  • Strong knowledge of data analysis and interpretation, contract oversight and monitoring
  • Knowledge of quality improvement methodologies such as NIATx, Six Sigma, Sterling Criteria, etc.
  • Excellent oral communication, public speaking, business writing, and presentation skills
  • Advanced proficiency in Microsoft Excel, Access, and PowerPoint
  • Familiar with the substance abuse and behavioral health system of care
  • Knowledge of federal and state regulations related to the provision of behavioral health services
  • Ability to represent CFCHS well at funder, Provider and community venues
  • Exceptional time management skills; ability to manage multiple tasks and prioritize to meet tight deadlines
  • Above-average knowledge of other computer applications, including Microsoft Office suite
  • Ability to travel as required by the position
  • Provide internal and external technical assistance


Standards of Performance

  • Corporate Culture – Understand and embrace corporate mission, vision, goals and guiding principles
  • Communication – Demonstrate accurate, clear concise and courteous internal/external verbal and written communication and presentations; demonstrate sound listening skills; represent CFCHS well in the community
  • Quality of Work – Demonstrate accurate, neat and thorough work; infrequent errors that have minimal or no negative impact to CFCHS
  • Quantity of Work – Demonstrate sound work habits; work output and timeliness positively impacts CFCHS’ overall performance
  • Dependability – Complete assignments and meet deadlines; punctual and infrequent unplanned absences
  • Interpersonal Skills – Maintain positive and cooperative attitude; work harmoniously with others; demonstrate effective conflict resolution and welcome constructive feedback
  • Initiative – Work independently, problem solve, identify cost efficiencies, assume additional responsibility and offer support and assistance to others as appropriate
  • Adaptability – Demonstrate flexibility and adaptability to changing priorities
  • Decision Making – Demonstrate logical and sound judgment; ensure decisions are made at the appropriate level of authority
  • Ethics – Adhere to Standards of Business Conduct; Demonstrate sound ethical principles in all situations; Comply with all confidentially standards, including HIPAA, as related to client and employee privacy
  • Safety – Adhere to safety standards at all times


*This position requires candidates to take an Excel assessment test during the interview process.

Central Florida Cares Health System, Inc. (CFCHS) is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, marital status, sexual orientation, gender identity, or military status, in any of its activities or operations.

CFCHS is a behavioral health administrative and management organization whose primary focus is to promote a comprehensive, seamless system of recovery and resiliency to individuals in the community who are in need of these services. CFCHS offers a comprehensive benefits package and is a smoke-free workplace.

All newly hired employees and volunteers must be screened through E-Verify. CFCHS does not share any E-Verify user ID or password and all personally identifiable information is safeguarded.

All candidates must successfully complete a pre-employment Level II Background Screening. Additionally, all candidates must provide a Local Law Criminal Background verification from the county of their residence.

CFCHS is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms without a valid written search agreement in place for this position will be deemed the sole property of CFCHS. No fee will be paid in the event the candidate is hired by CFCHS as a result of the referral or through other means.

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