Chief of Quality Management

Job Code: CQM - 129
Revised Date: April 8, 2025

Starting Salary: $44.75 hourly; $93,070 annually

FLSA: Exempt

Overview:

We are an agency committed to innovative behavioral health services in trauma-informed care that promote healing and recovery to instill a sense of empowerment and foster a lifelong sense of resilience.

Duties and Responsibilities:

The functions listed below are those that represent the majority of the time spent working in this position. Management may assign additional functions related to the type of work of the position as necessary.

The Chief of Quality Assurance is responsible for leading and overseeing the quality improvement, regulatory compliance, and risk management activities within a Certified Community Behavioral Health Clinic (CCBHC). This role ensures adherence to the National Association of Healthcare Quality (NAHQ) principles, Lean and Six Sigma methodologies, Joint Commission standards, and other applicable regulatory requirements. The Chief will collaborate across departments to foster a culture of continuous improvement, patient safety, and high-quality care delivery.

• Develop, implement, and manage the organization's Quality Assurance and Performance Improvement (QAPI) program.

• Lead quality initiatives aligned with NAHQ principles, applying evidence-based practices for quality measurement and improvement.

• Utilize Lean and Six Sigma methodologies to identify inefficiencies, reduce waste, and optimize processes.

• Establish and monitor key performance indicators (KPIs) and clinical outcomes to assess service quality.

• Collaborate with leadership and staff to implement corrective actions and process improvements.

• Ensure compliance with Joint Commission standards, CCBHC certification requirements, and state and federal regulations.

• Conduct routine audits, surveys, and assessments to monitor compliance and identify areas for improvement.

• Maintain current knowledge of relevant regulatory changes and provide guidance to leadership on implementation.

• Oversee the development, review, and revision of policies and procedures to ensure regulatory alignment.

• Provide leadership and direction to quality and compliance staff, ensuring a collaborative and proactive approach to quality improvement.

• Serve as the primary liaison for regulatory agencies, accreditation bodies, and external auditors.

• Facilitate cross-functional quality improvement teams, driving initiatives that enhance patient outcomes and operational excellence.

• Deliver training and education on quality and compliance topics to staff at all levels.

• Develop and manage a comprehensive risk management program, including incident reporting, root cause analysis, and corrective action implementation.

• Analyze trends in incidents and complaints to identify systemic issues and recommend preventive strategies.

• Ensure timely reporting and resolution of compliance concerns.

Minimum Education and Experience Requirements:

Requires a bachelor's degree in healthcare administration, nursing, public health, or a related field (master's preferred) or related major supplemented by eight (8) years of work experience. Lean Six Sigma Green Belt or Black Belt certification required. Minimum of 5-7 years of experience in healthcare quality, compliance, or related leadership roles. In-depth knowledge of Joint Commission standards, CCBHC requirements, and regulatory compliance. Proven ability to apply Lean and Six Sigma principles in a healthcare setting. Strong analytical, organizational, and communication skills. Experience leading multidisciplinary teams and driving quality improvement initiatives. Knowledge of data analytics and quality management software. Familiarity with electronic health record (EHR) systems and reporting tools.

Core Competencies:

• Leadership and strategic thinking

• Data analysis and interpretation

• Effective communication and collaboration

• Problem-solving using Lean and Six Sigma tools

• Risk management and regulatory compliance expertise

Required Knowledge and Abilities:

Knowledge of trauma-informed theories, principals, and practices (includes multi-faceted understanding of concepts such as community trauma, intergenerational and historical trauma, parallel processes, and universal precautions), preferred.

Physical Demands:

Performs sedentary work that involves walking or standing some of the time and involves exerting up to 10 pounds of force on a regular and recurring basis or sustained keyboard operations.

Unavoidable Hazards (Work Environment):

• None

Special Certifications and Licenses:

• Requires Certification in Project Management.

• Requires Certification in Audit and/or Risk Management.

• Must possess and maintain a valid state Driver's License with an acceptable driving record.

• Must be able to pass a TB, criminal background and drug screen.

Americans with Disabilities Act Compliance:

Emergence Health Network is an Equal Opportunity Employer.? ADA requires Emergence Health Network to provide reasonable accommodations to qualified persons with disabilities. Prospective and current employees are encouraged to discuss ADA accommodations with management.

Other Job Characteristics:

• Staffing requirements, including criteria that staff have diverse disciplinary backgrounds, have necessary State required license and accreditation, and are culturally and linguistically trained to serve the needs of the clinic's patient population.

• Credentialed, certified, and licensed professionals with adequate training in person-centered, family centered, trauma informed, culturally-competent and recovery-oriented care.

• Responsible for leading the EHN common purpose and service framework to continuously provide exceptional care to all constituents.

Note: This Class Description does not constitute an employment agreement between the Emergence Health Network and an employee and is subject to change by the Emergence Health Network as its needs change.