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Occurrence Reporter - HEALTH PROFESSIONAL III - Pueblo

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Occurrence Reporter - HEALTH PROFESSIONAL III - Pueblo

Salary

$63,456.00 - $88,860.00 Annually

Location

Pueblo, CO

Job Type

Full Time

Job Number

IIB 06223 5/15/2025

Department

Colorado Department of Human Services

Division

OBH (Office of Behavioral Health)

Opening Date

05/20/2025

Closing Date

6/4/2025 11:59 PM Mountain

FLSA

Determined by Position

Type of Announcement

This position is open only to Colorado state residents.

Primary Physical Work Address

Colorado Mental Health Institute at Pueblo, 1600 W 24th Street Pueblo, CO 81003

FLSA Status

Exempt; position is not eligible for overtime compensation.

Department Contact Information

[email protected]

Salary Note

Although the full salary range for this position is provided, appointments are typically made at or near the range minimum.

How To Apply

Please submit an online application for this position at https://www.governmentjobs.com/careers/colorado. Reach out to the Department Contact to apply using a paper application, including any supplemental questions. Failure to submit a complete and timely application may result in the rejection of your application. Applicants are responsible for ensuring that application materials are received by the appropriate Human Resources office before the closing date and time listed.

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Department Information

This position is open only to Colorado state residents.

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Description of Job

Job Assignment

The Quality Management Department (QM) exists to provide guidance to the Colorado Mental Health Hospital in Pueblo’s efforts to meet or exceed customer expectations by maintaining excellence in patient care and to identify opportunities for improvement through analysis, interpretation and dissemination of data-based information that enables hospital leadership to utilize resources in an efficient manner and to operate effectively under legislative mandates and administrative policies.

This position exists to assist with the implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 25-3-109. This position reviews and analyzes incident reports, using the standards of practice set by the Colorado Department of Public Health and Environment (CDPHE), and provides follow up for Colorado Mental Health Institute at Pueblo (CMHHIP), Office of Behavioral Health (OBH), and Colorado Department of Human Services (CDHS). Investigates and determines which events constitute a critical incident/occurrence and determines which of those must be reported to Executive Management in Denver, CMHHIP leadership, including the hospital CEO and the Deputy Director of Clinical Services for OBH and Colorado Department of Public Health and Environment (CDPHE). Collaborates with Program/Unit Leadership, Department of Public Safety (DPS) and appropriate Department Heads to respond to and investigate serious allegations that may require immediate response of an appointing authority to determine appropriate action to keep patients safe at all times.

Participates in root cause analysis investigations to direct formulation of quality improvement strategies. Managers and peers internally and externally to CMHHIP rely on this pacesetter when making decisions regarding course of action, policy revisions or programmatic changes that would be appropriate to maintain optimum patient safety and ongoing treatment. Generates a weekly report from the database which is disseminated to hospital leadership and appropriate OBH Leadership. Recommends updates to policy and procedure and sits on policy committees.

Maintains updated knowledge of standards: 27-65 Statute, CMS, JCAHO and Health Department. Assists in all onsite survey activities (accompanying surveyors throughout the hospital) and/or provides assistance to the Director of QM with completion of the Joint Commission's Focused Standards Assessment (FSA) which is submitted to TJC in non-survey years. ADHOC Reference Committee member for the Policy and Procedure process that is utilized for ongoing policy and procedure updates which is based in QM.

Job Duties:

Critical Incident/ Occurrence Investigation and Reporting:

+ Ongoing development and implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 25-3-109.

+ Collects, analyzes and reports data related to hospital-wide incidents in order to improve patient and staff safety.

+ After investigating the incident and assessing the data collected, determines which events constitute an occurrence that must be reported through the iNotify database to Executive Management in Denver, CMHHIP/OBH leadership, including the hospital CEO and the Deputy Director of Clinical Services for OBH.

+ Investigates and conducts mini root cause analyses into the incidents to further determine which incidents rise to the level of required reporting to the Colorado Department of Public Health and Environment (CDPHE) or the Joint Commission (TJC) as a Sentinel Event.

+ Investigates and develops follow-up reports on any occurrence that meets the criteria, which includes, but is not limited to, visual review of video footage, performing interviews alone with staff and patients, recording interviews, listening to recordings, searching areas of the hospital, entering patient care areas and reviewing documentation.

+ Additionally, this position is involved in the completion of Apparent Cause Analysis and Root Cause Analysis for critical incidents investigations.

+ This position is required to complete emergency physical intervention/restraint training (CTI) and CPR.

+ Collaborates with and advises Program and Unit Leadership, Department of Public Safety and Department Heads to respond to and investigate serious allegations that may require immediate response of an appointing authority to determine and develop an appropriate action to keep patients safe at all times.

+ Formulates recommendations for change or improvement in operating procedures.

Medical Records Audits and Audit Monitoring:

+ Completes audits under the direction and in collaboration with the Quality Management QAPI team.

+ Collects and summarizes findings by aggregating data per regulatory guidelines.

+ Reports findings to the Director of Quality Management, and QAPI Supervisor.

+ Assists with completing data input and collaborates on system maintenance for Quality Management spreadsheets and databases for audits, focused audits or focused audits Requested by legitimate special interest entities affiliated with CMHHIP and TJC Tracers.

+ Assists in determining the best method of data presentation based on the intended audience.

+ Uses an established database in which results of all audits are maintained and through which comprehensive reports (including graphs and charts) may be extracted for the Director of Quality Management, Executive Committee or Program and Department Heads.

+ Maintains a system for tracking chart delinquencies with a goal of no delinquencies older than 30 days hospital-wide.

+ Monitors delinquencies and works with clinical staff to correct them within established timelines.

+ Coordinates resolution of delinquencies with Quality Management QAPI team.

+ Provides reports on delinquencies to the Director of Quality Management and Quality Management QAPI supervisor.

+ As part of the utilization management program, this position may be asked to participate in various aspects of utilization review.

+ For example, compose clinical letters in reply to third-party payer denial for reimbursement, and auditing the medical record to determine if there is additional documentation to be included to support medical necessity.

Survey Readiness-Tracers:

+ Under direction of the Quality Management Director, provides back-up support in the Tracer process, which mimics the tracer methodology employed by the Joint Commission when they conduct on-site surveys for themselves and CMS.

+ Uses knowledge of Joint Commission and CMS Standards to complete intense observation of all areas, to include patient care areas, assessing environment of care, patient-staff interactions, observation of medication administration, seclusion and restraint, programming, plan of care reviews etc.

+ It also involves detailed audits of medical records on each unit visited to ascertain compliance with Joint Commission/CMS Standards.

+ Tracers also review ancillary services such as Radiology, Clinics, and Physical Therapy etc.

+ This position specifically reviews Ambulatory Care Services, Physical Therapy, Dental Services and Radiology.

Other Duties as Assigned:

+ Responsibility to perform assigned tasks and duties within the scope of practice for this position that do not fall within the realm of duty statements A-C to meet the vision and mission of the agency and/or the department.

Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights

Minimum Requirements:

Experience Only:

Six (6) years of relevant experience in an occupation related to the work assigned to this position. Relevant experience in a clinical or hospital setting and/or Behavioral Health experience

OR

Education and Experience:

A combination of related education and/or relevant experience in an occupation related to the work assigned equal to six (6) years.

Acceptable degree plans include: Clinical Nursing, Psychology , Social Work ,etc.

Note: Please be sure to indicate related experience in each job experience listed, as these will determine calculations of related experience.

Preferred Qualifications:

+ Demonstrated computer proficiency

+ Well developed interpersonal skill: ability to remain professional in stressful situations

+ Attention to detail

+ Well developed and demonstrated writing skills

+ Bachelor's degree or higher in the clinical field of Counseling, Psychology, Nursing, or Social Work.

+ Five or more (5+) years of experience working in a clinical or hospital setting.

+ Behavioral health experience

+ Experience investigating occurrences

+ Prior utilization management experience

+ Experience in writing professional reports

+ Prior experience interacting with regulatory entities

+ Previous experience in quality improvement measures

+ Data collection and analysis

+ Experience with Google Suite Applications

Conditions of Employment

+ A pre-employment criminal background check will be conducted as part of the selection process as this position is deemed to have direct contact with vulnerable persons. Felony convictions, conviction of crimes of moral turpitude, or convictions of misdemeanors related to job duties may disqualify you from being considered for this position. Should your background check reveal any charges or convictions, it is your responsibility to provide the CDHS Background Unit with an official disposition of any charges.

+ A Tuberculosis Test (TB) will be required upon hire

+ May work weekends or alternate shifts/schedules

+ Shall not initiate or engage in sexual, social, personal or financial relationships with patients either during or any time after hospitalization, even if the patient requests or initiates such relationship.

+ Successfully pass all modules of the CMHHIP New Employee Orientation core curriculum to include English reading comprehension, relevant competency assessments and written/practical exams;

+ Work in situations involving assaultive behavior;

+ Former State employees who were disciplinarily terminated or resigned in lieu of termination must disclose the information on the application and provide an explanation why the prior termination or resignation should not disqualify the applicant from the current position. Absent extraordinary circumstances, prior disciplinary termination or resignation in lieu of termination will disqualify the applicant from future State employment with CDHS.

Appeal Rights:

If you receive notice that you have been eliminated from consideration for this position, you may file an appeal with the State Personnel Board or request a review by the State Personnel Director.

An appeal or review must be submitted on the official appeal form, signed by you or your representative. This form must be delivered to the State Personnel Board by email ([email protected]), postmarked in US Mail or hand delivered (1525 Sherman Street, 4th Floor, Denver CO 80203), or faxed (303.866.5038) within ten (10) calendar days from your receipt of notice or acknowledgement of the department’s action.

For more information about the appeals process, the official appeal form, and how to deliver it to the State Personnel Board; go to spb.colorado.gov ; contact the State Personnel Board for assistance at (303) 866-3300; or refer to 4 Colorado Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, at spb.colorado.gov under Rules.

Supplemental Information

How to Apply (https://cdhs.colorado.gov/information-for-job-applicants#how-to-apply)

The Assessment Process

For additional recruiting questions, please contact jonathan.benavides @state.co.us

About Us:

If your goal is to build a career that makes a difference, consider joining the dedicated people of the Colorado Department of Human Services (https://www.colorado.gov/cdhs) (CDHS). Our professionals strive to design and deliver high quality human and health services that improve the safety, independence, and well-being of the people of Colorado. In addition to a great location and rewarding and meaningful work, we offer:

+ Strong, secure, yet flexible retirement benefits including a PERA Defined Benefit Plan or PERA Defined Contribution Plan www.copera.org plus 401(k) and 457 plans

+ Medical and dental health plans

+ Employer supplemented Health Savings Account

+ Paid life insurance

+ Short- and long-term disability coverage

+ 11 paid holidays per year plus vacation and sick leave

+ BenefitHub state employee discount program

+ Employee Wellness program MotivateMe

+ Excellent work-life programs, such as flexible schedules, training and more

+ Remote work arrangements for eligible positions

*Some positions may qualify for the Public Service Loan Forgiveness Program. For more

information, go to https://www.colorado.gov/pacific/dhr/student-loan-forgiveness-programs .

Our Values:

We believe in a people-first approach: To serve the people of Colorado, we develop a culture and work environment that creates an energized, inspired, and healthy team capable of giving their best to Coloradans .

Balance creates quality of life: We want our team to be resilient through a supportive workplace that values flexibility, health and wellness, and employee engagement.

We hold ourselves accountable: We take responsibility through our actions, programs, and results for the state of health and human services in Colorado.

Transparency matters: We are open and honest with employees, our partners, the Coloradans we serve, and the public.

We are ethical: We abide by what is best for those we serve by doing what is right, not what is easy.

Collaboration helps us rise together: We work together with all partners, employees, and clients to achieve the best outcomes for Coloradans.

We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore, we encourage responses from people of diverse backgrounds and abilities.

ADAA Accommodations: CDHS is committed to the full inclusion of all qualified individuals. As part of this commitment, our agency will assist individuals who have a disability with any reasonable accommodation requests related to employment, including completing the application process, interviewing, completing any pre-employment testing, participating in the employee selection process, and/or to perform essential job functions where the requested accommodation does not impose an undue hardship. If you have a disability and require reasonable accommodation to ensure you have a positive experience applying or interviewing for this position, please direct your inquiries to our ADAA Coordinator, Nancy Schmelzer, at [email protected] or call 1-800-929-0791.

~THE STATE OF COLORADO IS AN EQUAL OPPORTUNITY EMPLOYER~ (https://cdhs.colorado.gov/information-for-job-applicants#eoe)

Toll Free Applicant Technical Support (https://cdhs.colorado.gov/information-for-job-applicants#technical-support)

THE CAMPUS OF THE COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO IS TOBACCO FREE.

The State of Colorado offers permanent employees a variety of benefits including medical, dental, life and disability insurance, as well as a comprehensive leave program. Please click the following link for detailed information: www.colorado.gov/pacific/dhr/benefits

Please note that each agency's contact information is different; therefore, we encourage all applicants to view the full, official job announcement which includes contact information and class title. Select the job you wish to view, then click on the "Print" icon.

01

Describe your experience working with psychiatric patients

02

Please describe your experience in auditing, including years.

03

Describe your experience communicating with accrediting agencies

04

What is your experience related to occurrence reporting?

05

What experience do you have with quality assurance and performance improvement?

06

If you are a current or former State of Colorado employee, please list your employee number (starts with 997…). Failure to provide this requested information may render your application incomplete, and you may no longer be considered for the position.

07

Your legal name is used in the hiring process for background checks. Did you use your full legal name in your application? If not, please update your information before submitting your application. Yes/No

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08

The bottom of this job announcement provides links to additional information on how to apply, the assessment process, toll free applicant technical support, and about how the State of Colorado is an equal opportunity employer. Please acknowledge below that you have read the information provided in these links.

+ This information is available to me and I have read this information

+ I am unable to access the links with this information on the job posting. (If you select this option, please contact the recruiter, whose information is listed on this announcement, so that they can send this information directly to you.)

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