Director of Quality Improvement

Primary Responsibilities: Provide leadership and support in establishing and directing the Quality Improvement Program consistent with all regulatory requirements. Develop and execute a comprehensive quality strategy that advances clinical excellence, client safety, recovery-oriented care, health equity, population health, and measurable outcomes. Lead the evaluation of care-delivery models and collaborate with clinical and operations teams to identify opportunities, implement evidence-based improvements, and sustain high-quality services across the organization. Lead the development of key performance indicators, outcomes measures, data-collection methods, benchmarks, and reporting structures used to monitor clinical quality, regulatory compliance, client experience, and organizational performance. Guide multidisciplinary teams in testing, evaluating, scaling and sustaining changes that improve workflows, clinical outcomes, access to services, care coordination, and client experience. Collaborate closely with the Compliance Director to lead organizational readiness for CARF accreditation, DOH licensing, certifications, contractual, and all other external audit requirements. Direct gap analyses, mock reviews, corrective action plans, and improvement activities to ensure alignment with organizational policies, applicable quality standards, state regulations, and other requirements. Develop executive-level reports, dashboards, presentations, and recommendations that translate complex findings into clear, actionable insights for clinical, operational, and governance audiences. Work collaboratively with leaders across the organization to support quality improvement, population health, and health equity initiatives. Build organizational capability improvement by coaching leaders and staff, facilitating multidisciplinary teams, and providing education on measurement and process improvement. Employ Plan-Do-Study-Act cycles (PDSAs) and other improvement methods to evaluate and strengthen organizational workflows. Promote understanding and adoption of evidence-based and data-driven best practices throughout the agency. Analyze processes, policies, and systems to ensure continued alignment with regulatory requirements and accreditation standards. Lead the dissemination of quality improvement information and performance data to leadership and committees. Communicate quality goals, improvement priorities, and performance results to employees across the organization. Plan and facilitate quality committee meetings and ensure timely follow-up on action items and improvement activities. Participate in evaluations and audits and develop associated action plans and quality improvement objectives. Maintain current knowledge of regulatory requirements associated with the Quality Improvement Program. Oversee the Community Advisory Council and communicate quality improvement recommendations and community feedback to KMHS Leadership and the Board of Directors. Hire, train, coach, and supervise quality improvement staff. Collaborate with the Chief Compliance and Privacy Officer in the annual performance review process.

EDUCATION: Bachelor’s degree in nursing, social work, psychology, behavioral health, healthcare administration, public health, quality improvement, or related subject.

EXPERIENCE: Seven (7) or more years of progressively responsible job experience in healthcare quality improvement, behavioral health administration, regulatory compliance, or program evaluation. Experience supporting accreditation, regulatory, or patient safety initiatives. Four or more years of experience working in a healthcare setting, including hospitals, ambulatory care, community health, or managed care environments. Experience managing organizational risk and liability issues. Three years of management or supervisory experience.

EDUCATION: Master’s degree in nursing, social work, psychology, behavioral health, healthcare administration, public health, quality improvement, or related subject.

LICENSE/CERTIFICATION: Certified Professional in Healthcare Quality (CPHQ). Formal Project Management training or certification.

Performance Requirements: KNOWLEDGE:Knowledge of applicable clinical principles and practices. High-level knowledge of HIPAA and HITECH security regulations and other confidentiality and health information protections and their impactsin the clinical practice setting. Working knowledge of legal statutesand quality improvement strategies that govern clinical skills, clinical documentation, and agency operations. Federal, state, and local regulations in the behavioral healthcare field. Familiarity with the Diagnostic and Statistical Manual, fifth edition (DSM-5) of Mental Health Disorders, the ASAM Criteria, and quality improvement processes at a systemic level.

SKILLS: Excellent communication and skill in establishing and maintaining effective working relationships with other employees, patients, organizations, and the public. Confidentiality, diplomacy, and judgmentin sensitive situations. ABILITIES:Guide individuals and groups towarddesired outcomes, setting high-performance standards and delivering leading quality services. Use adaptiveleadership and a systems approachto implement effective, organization‑wide improvements. Establish and maintainlong-term relationships with both internaland external customers, building trust and respect by consistently meeting and exceeding expectations. Ability to anticipate concerns and overcome objections. Articulate knowledgeand understanding of organizational policies, procedures, and systems. Proficient in Microsoft Officeapplications and the ability to navigate an EMR system and other applications as required with minimal training. Worksite-Specific Requirements: check applicable worksite(s)RWORKSITE #1: Campbell CampusREQUIREMENTS: No additional requirements for this worksitelocation. RWORKSITE #2: Remote WorksiteREQUIREMENTS: Employees approved for remote work must maintain a safe, secure, and professional workspace with reliable internet, ensure confidentiality and compliance with KMHS policies (including HIPAA), and remain fully available and responsive during scheduled work hours. Equipment Operated: Standard office equipment including computers, fax machines, copiers, printers, telephones, etc.

Work Environment: Office, remoteworkspace. Mental/Physical

Requirements: While performing the essential functions of the job, the employee is required to:

• Sit, stand, and walk for extended periods.
• Lift, carry, push, and pull:
• Up to 10 pounds (frequently)
• Up to 20 pounds (occasionally)
• Up to 50 pounds (seldom)
• Use hands and arms for reaching, handling, and manipulation, includingreaching above shoulder level.
• Have visual acuityand peripheral vision sufficient to read writtenmaterials and observe surroundings.
• Have hearingsufficient to communicate effectively.
• Our recruitment processes are designed to prevent discrimination against our people regardless of gender identity or orientation, religion, ethnicity, age, neurodiversity, disability status, citizenship, or any aspect which makes someone unique.