Description:

This is a fully onsite position

Position Scope

The Director of Quality is responsible for leading, planning, enhancing, implementing and overseeing all quality improvement, compliance, and performance management initiatives across Pawnee Mental Health’s Services’ programs. This role ensures the delivery of high-quality, client-centered care through the development, implementation, and monitoring of evidence-based practices, outcome measures, and regulatory standards. The Director of Quality plays a key role in driving continuous quality improvement (CQI) for quality metrics on the CCBHC, CMHC and SUD licensure levels, supporting clinical excellence, enhancing operational efficiency, and maintaining CCBHC certification compliance.

The Director of Quality works closely with the Chief Clinical Officer, Chief Financial Officer, Director of Operations, Director of Human Resources, Director of Marketing, Compliance Officer, and other key managers and staff to ensure a coordinated, data-driven, and outcome-oriented approach to service delivery. This position also serves as a liaison with state and federal agencies, and accrediting bodies to promote access to care, ensure clinical integration, and meet regulatory and performance expectations.

The Director of Quality will provide leadership in standardizing quality protocols, tracking and analyzing performance indicators, ensuring interdepartmental collaboration, and embedding a culture of excellence, accountability, and client-safety throughout the organization.

Responsibilities and Qualifications

Client Complaints, Grievances & Advocacy

Oversee the process and resolution of grievances.
Coordinate with program supervisors to investigate and resolve client concerns promptly; ensure all follow-up communication is completed and documented.
Maintain an ongoing tracking and trending system for complaints and grievances to identify systemic issues and drive service improvements.
Conduct satisfaction phone calls and case-specific inquiries when concerns regarding clinical care arise.

Risk Management & Incident Oversight

Serve as the designated Risk Manager for the agency.
Review and analyze all incident reports, determine the applicability of standard of care and identify opportunities for process or system improvements.
Maintain a system for tracking and trending incidents and use findings to inform leadership and staff training initiatives.
Lead agency responses to potential legal action related to client care; coordinate with internal leadership and legal counsel as needed.

Regulatory Audits & Accreditation

Lead the agency’s preparation for and response to all audits, including KDADS (Kansas Department for Aging and Disability Services) and other regulatory bodies.
Ensure compliance with standards for CCBHC, CMHC, SUD and other licensing/accrediting entities.
Oversee internal audits and lead the development and monitoring of corrective action plans

Legal Compliance & Subpoenas

Serve as the designated Privacy Officer for the agency.
Manage all subpoenas, coordinating with legal counsel to ensure proper response and risk mitigation.
Ensure agency billing policies are followed for subpoena responses.
Handle all Subpoena Duces Tecum requests and serve as Custodian of Medical Records in court, allowing clinical staff to continue client care without disruption.

Committees & Leadership Facilitation

Chair the Policy Committee, ensuring policies align with regulatory requirements, ethical standards, and organizational goals.
Regularly participate in Safety Committee meetings and activities, to assess risk and enhance safety protocols across sites.
Lead the Peer Review Committee, supporting ongoing clinical quality review and accountability.
Participate as an active member of the Compliance Committee and other cross-functional teams.

Regulatory Audits & Accreditation

Lead the agency’s preparation for and response to all audits, including KDADS (Kansas Department for Aging and Disability Services) and other regulatory bodies.
Ensure compliance with standards for CCBHC, CMHC, SUD and other licensing/accrediting entities.
Oversee internal audits and lead the development and monitoring of corrective action plans.

Performance Improvement & Quality Metrics

Direct the agency’s Performance Improvement Program, including oversight of the annual quality plan.
Track and trend Utilization Review data to identify service gaps, monitor efficiency, and guide clinical decision-making.
Lead satisfaction survey initiatives and use data to inform quality improvement, though current survey implementation is impacted by limited capacity.

Health Information & Privacy

Oversee aspects of electronic health record (EHR) management specific to support for data integrity (e.g., merging duplicate records, correcting client information).
Ensure compliance with HIPAA, 42 CFR Part 2, and other privacy regulations through staff training, internal audits, and direct oversight.
Maintain the privacy and security of all client information in both digital and physical formats.

Staff Development, Training & Consultation

Provide training and onboarding on compliance, risk management, incident reporting, and quality assurance protocols.
Provide coaching and supervision to staff; deliver timely performance feedback to support accountability and growth.

Organizational Leadership & Representation

Serve as a strategic advisor to the CEO and Management Team on matters related to quality, risk, and compliance.Represent the agency in external meetings, reviews, and legal proceedings as applicable and as delegated by the CEO.
Operate a vehicle as required to perform duties across multiple agency locations.
Maintain current knowledge of regulatory standards, quality improvement practices, and risk management principles through ongoing professional development.
Other duties as assigned by the CEO.

Requirements:

Qualifications:

Required:

Master’s degree in Healthcare Administration, Public Health, Psychology, Social Work, Nursing, or related field (required).

Minimum of 5 years of experience in quality management or compliance in behavioral health or healthcare.
Experience with data analysis, process improvement (e.g., Lean, Six Sigma), and clinical auditing.
Strong leadership, communication, and team collaboration skills.
Ability to exercise discretion and confidentiality regarding sensitive matters.

Preferred:

Understanding of the CCBHC model requirements, performance metrics, and quality standards is highly desired.
Certification as CPHQ, HCQM, CHC, CCEP, CHP is highly desired.
Supervisory experience of at least 3 years.

All employees will be required to submit to and pass a background check and drug screening.

Pawnee Mental Health Services Inc

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Director of Quality Management