Assistant Director of Quality Assurance

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Functional Title: Assistant Director of Quality Assurance 
Job Title: Program Specialist IV 
Agency: Health & Human Services Comm 
Department: Quality Mgmt 
Posting Number: 10592 
Closing Date: 01/25/2026 
Posting Audience: Internal and External 
Occupational Category: Office and Administrative Support 
Salary Group: TEXAS-B-20 
Salary Range: $4,263.16 - $6,779.25 
Pay Frequency: Monthly
Shift: Day 
Additional Shift: Days (First) 
Telework: Not Eligible for Telework 
Travel: Up to 10% 
Regular/Temporary: Regular 
Full Time/Part Time: Full time 
FLSA Exempt/Non-Exempt: Nonexempt 
Facility Location: Big Spring State Hospital 
Job Location City: BIG SPRING 
Job Location Address: 1901 N HIGHWAY 87 
Other Locations: Big Spring 
MOS Codes: 16GX,60C0,611X,612X,63G0,641X,712X,86M0,8U000,OS,OSS,PERS,YN,YNS 
 
 
 

Brief Job Description:

Would you thrive in an environment where you learn and grow personally and professionally all while helping make a positive impact on people’s lives? Do you appreciate being around others like yourself who are dependable, trustworthy, hard workers who believe in the value of each other, teamwork, and inclusivity? HSCS is dedicated to building a diverse community atmosphere where employees feel valued, supported, and accepted while providing specialized care for Texans in need. If providing hope and healing through compassionate, innovative, and individualized care interest you, we welcome your application for the position below.

The Assistant Director of Quality Assurance performs administrative support and/or technical program assistance work in a state agency. Work involves assisting in the management and operations of QM. Works under general supervision with considerable latitude of the use of initiative and independent judgment. Responsible for data analysis of assigned databases. Assists with local Governing Body processes, coordinates OPM processes, monitors the environment for compliance with standards, and assists with special projects. Assists in establishing and maintaining an environment that is therapeutic for individuals with mental illness. Requires physical and mental abilities to learn and perform the essential job tasks. Must understand that duties, location of work and shift/pattern are subject to change as determined by the administration to meet the needs of the hospital.

Ensures the facility conforms to the conditions of participation for the facility as a Centers for Medicaid and Medicare Services (CMS) provider serving persons with mental health diagnoses, the Joint Commission (TJC) standards, and all other relevant state and federal laws, rules, and regulations.  Interprets regulations/standards, develops, and disseminates policy and coordinates a comprehensive system of implementing and reporting on quality enhancement efforts. Assists in the development of in-service/training modules to address issues as needed. Analyzes data from multiple sources for trends, systemic issues, and areas for improvement, including verifying accuracy of data.  Develop reports as directed.  Assists in hiring, development, plans, assigns, and supervises the work of others. Serves on and/or chairs other committees and work groups as indicated.  Works collaboratively with all other department leads.

Essential Job Functions (EJFs):

Attends work on a regular basis and may be asked to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned.

Assists the Quality Assurance Director in the supervision of program auditor(s), data analysts, records coordinators, Clinical Safety Coordinator and/or Nurse Auditor(s) and administrative/clerical staff. Assists in hiring, training, of the employees within the department so that a competent workforce is maintained. Ensures that all departmental staff are compliant in training per agency and facility standards. Conducts performance evaluations of assigned staff to give employees timely feedback on their performance and oversees staff development plans and activities.

Provides support to departments in data collection, monitoring, analysis, and reporting. Ensures the collection of information in a timely and efficient manner and ensures the use of that information to identify performance issues and make decisions. Proactively identifies potential problems. Reports potential and actual problems to the appropriate supervisor/manager for corrective action.  Provides feedback to discipline coordinators/department leads for process improvement. 

Monitors the TJC website for regulatory announcements including survey visits. During visits from HHSC-Regulatory, CMS and TJC meets with surveyors at the entrance and exit meetings. Ensures surveyors receive all documentation requested, providing contact information for staff, patients and families as needed.  Answers surveyor questions regarding policies/procedures.  Notifies all required parties of the entrance of HHSC-Regulatory, CMS and TJC at the SH in accordance with established protocols. Assists in annual focus of standards reviews. Coordinates technical aspects for surveys, e.g., room arrangements, scheduling, etc.

Assists the Quality Assurance Director in oversite of the work of staff auditors to ensure statistical analysis of data and database design is conducted, to maintain a center-wide list of all data collected by department, to maintain the databases that the QA and discipline departments use to enter results from monitoring tools. Ensures that data is collected via a facility-wide monitoring system that can be trended by required parameters.

Develops plans of correction (POC) when indicated, CMS or TJC.  Ensures POCs include measurable outcomes and appropriately address the identified issue(s), that the outcomes are monitored.  Ensures that all due dates noted in the POC are met, and that evidence supporting the plan is collected and organized in accordance with the SH protocol.  Presents the evidence to the surveyors upon their return visit.

Develops localized policies and procedures to implement state policy and ensures those documents are posted on the required site and are updated as needed. Develops in-service/training modules as needed to address issues.  Ensures all staff are trained on policy changes as required.  Ensures in-services/trainings on policies and procedures are conducted in conjunction with POCs and documentation is accurately maintained. Prepares any required reports. 

Performs other duties as assigned. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

Coordinates and documents Quality Improvement Council and Hospital Executive Committee documents and minutes and coordinates presentation content including the scheduling of reports. Coordinates National Research Institute requirements and responsible for review of data findings including DACA requirements. Completes quarterly and annual reports as assigned. Attends the daily Morning Report meeting to ensure that injuries and incidents are addressed appropriately. Participates on other work groups as needed to promote collaboration and operational effectiveness.  Finalizes and maintains the facility automated OPPM’s. Coordinates meetings, documents, schedules and documentation of Root Cause Analysis (RCA), and death reviews. Coordinates special projects for QM. Coordinates Incident Reporting Program and ensures incidents are reported, tracked and analyzed. Coordinates the annual American Hospital Association Survey. Coordinates Governing Body reporting to include quarterly and annual reviews. Responsible for coordination of end of the year Committee and Department reports are completed and submitted for review. Responsible for coordination of submission of annual departmental services description.

Knowledge, Skills and Abilities (KSAs):

Knowledge of office practices and administrative procedures.

Ability to take minutes in leadership group settings.

Skills in prioritizing and organization.

Knowledge of CMS conditions of participation, The Joint Commission standards, interpretive guidelines, and survey process. 

Knowledge of Texas Administrative Code, HHSC policies and procedures related to State Hospitals.

Knowledge of and experience in ensuring the provision of quality services, treatment, training and supports for individuals with a mental health diagnosis.

Knowledge of developing and implementing plans of correction.

Knowledge of how a quality improvement program effects positive change on the implementation of services.

Skills in defining problems, collecting data, establishing facts, conducting root cause analysis.

Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.

Skills in using computers and agency/facility software including, but not limited to, Microsoft Word, Excel, PowerPoint, Access, Outlook, and SharePoint.

Skill in motivating all levels of staff.

Skill in facilitating change.

Skill in writing quality improvement plans.

Skill in developing and implementing a tracking system.

Skilled with task management, working with teams, delegation and/or leading/prioritizing the work of others.

Ability to develop written policies/guidelines to ensure facility compliance with applicable standards. 

Ability to gather, assemble, and correlate data for trend analysis.

Ability to effectively facilitate work groups and meetings.

Ability to organize and present information effectively, both in spoken and written word, to a wide variety of audiences.

Ability to analyze and solve complex problems and to make effective decisions.

Ability to plan, assign, and supervise work of others.

Ability to manage time with latitude for independent judgement, 

Ability to maintain flexibility in work hours, which may require overtime or extended hours.

Ability to communicate effectively orally and in writing; attention to detail (as demonstrated in interview and on application).

Ability to articulate vision for quality improvement and concrete implementation plans.

Registrations, Licensure Requirements or Certifications:

None required

Initial Screening Criteria:

Experience in administrative support work or the technical program area. Graduation from an accredited four-year college or university with major course work in a field related to program area is generally preferred. Experience and education may be substituted for one another. 

Additional Information:

Applicants must pass a fingerprint criminal background check, pre-employment drug screen, and registry checks including the Client Abuse/Neglect Reporting System (CANRS), Nurse Aid, Medication Aide and Employee Misconduct, List of Excluded Individuals/Entities (LEIE). Males between the ages of 18-25 must be registered with the Selective Service.

All applicants must be at least 18 years of age to be considered for employment at a state-operated facility. Waco Center for Youth applicants must be 21 years of age.

Flexibility in work hours may be required for this position. The position may be required to work overtime and/or extended hours.

Compliance with HHSC immunization policy and state hospital operating procedures related to immunizations is required. According to the Centers for Disease Control and Prevention, healthcare workers are at significant risk for acquiring or transmitting hepatitis B, measles, mumps, rubella, varicella (chicken pox), tetanus, diphtheria, pertussis (whooping cough), and influenza. All these diseases are vaccine preventable. Vaccines may be provided. As a result, state hospital policy requires employees be vaccinated according to their level of contact with individuals. In the event you choose to not be immunized for the influenza virus, you may be required to wear a mask and take other protective measures.

Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC.

Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.