Hybrid Director of Quality Managment chez Pawnee Mental Health

Description

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

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.