Job Summary and PurposeThe Director of Quality Improvement and Privacy leads the organization's quality improvement program, which serves as the umbrella over compliance, risk management, outcome evaluation, accreditation, policy management, and privacy. The Director ensures compliance with applicable state and federal regulations, licensing requirements, accreditation standards, and payer contracts, and promotes a culture of safety, continuous learning, trauma informed care, and family centered services throughout Tennyson. The Director serves as Tennyson Center's designated Privacy Officer, serves as the PolicyTech system administrator, and supervises the Health Record Analyst. Health information management and client health data integrity are led within Finance and Operations, and the Director partners with the Electronic Health Record Administrator and the Chief Financial and Operations Officer so that audit findings and privacy requirements are addressed.
Essential Job FunctionsCompliance, Accreditation and Licensing (COA and CDHS)- Develop and manage Tennyson Center's compliance program, including related policies and compliance reviews, to ensure compliance with state and federal regulations, licensing requirements, accreditation standards, and payer contracts, especially CDHS Child Welfare Volume 7 and Community Services Volume 8, CDE requirements, and FERPA/IDEA
- Lead Tennyson Center's Council on Accreditation (COA) accreditation process and the annual CDHS licensing process, and ensure ongoing readiness for all programs
- Lead CDHS TRAILS reporting and background checks, the response to CDHS Reports of Investigations (ROIs) within required timeframes, maintain relationships with regulatory bodies, and recommend investigative procedures when violations are alleged
- Serve as the subject matter expert in accreditation and licensing, communicating survey status, gaps, and readiness to the Chief Program Officer and CEO and partnering with department directors to implement corrective plans
Risk Management - Administer the risk management program in collaboration with the Chief Financial and Operations Officer, covering adverse events, client rights and grievances, facility and staff safety, and media and reputational risks
- Oversee incident reporting, grievance tracking, and investigations, and review critical incidents and reportable events, for timeliness, regulatory compliance, and appropriate, trauma-informed interventions
- Identify trends and root causes, recommend preventive actions, and escalate significant safety, privacy, or compliance concerns to the Chief Program Officer and CEO
Onboarding and Training - Develop and deliver onboarding and annual training for all staff in risk management, compliance, audits, privacy and HIPAA, quality standards, documentation procedures, and client rights, and assess staff's ongoing compliance knowledge, in partnership with Human Resources
Impact and Outcome Evaluation and Reporting - Gather, validate, and report data from quality improvement and risk management processes, including key performance indicators (KPIs), monthly, quarterly, and annually
- Lead development of the organizational dashboards, monitor clinical outcomes and strategic plan progress, and communicate results to the Chief Program Officer, senior leadership, and CEO
- Prepare quality reports and presentations of impact for leadership, committees, the Board of Directors, and marketing and development
Quality Improvement - Develop, implement, and oversee the organization's quality and performance improvement program, using a closed loop Continuous Quality Improvement (CQI/PQI) approach across all programs
- Lead quality improvement initiatives focused on client safety, treatment effectiveness, family engagement, and outcomes for youth, including restraints use, elopements, timely reporting of abuse and neglect allegations, client record audits, and staff retention
- Develop and monitor performance indicators, corrective action plans, and improvement goals, and conduct internal audits and chart reviews as appropriate
- Review the quarterly SmartCare audits conducted by the Electronic Health Record Administrator and recommend corrective actions
- Collaborate with clinical and executive leadership to add new programs into the CQI process, hold staff accountable for accurate data collection, and support continuous improvement
PolicyTech System Administrator - Serve as the system administrator for PolicyTech, Tennyson Center's electronic policy management system, including periodic policy review, approval, and version control
- Work with policy owners to revise policies based on regulatory changes, audit findings, and incident trends, and oversee forms management and document control
Privacy Officer - Serve as Tennyson Center's designated Privacy Officer, with oversight of all privacy issues, including HIPAA/individual health records privacy, security, and breach notification requirements, the HITECH Act, FERPA/IDEA.
- Maintain privacy policies, procedures, and notices, and oversee technology and security safeguards that affect privacy in collaboration with Information Technology and the Electronic Health Record Administrator
- Investigate suspected privacy violations and breaches of unsecured PHI, and ensure required notifications, including to the HHS Office for Civil Rights, are completed on time
- Coordinate privacy complaints and risk assessments, and document investigations and corrective actions
Leadership and Supervision - Supervise, coach, and evaluate the Health Record Analyst, and partner with the Electronic Health Record Administrator and the Chief Financial and Operations Officer on health information management and data integrity
- Perform other duties as assigned
Physical Requirements - Must be able to successfully complete a pre-hire physical
- Minimal physical requirements, occasional lifting up to 10 pounds
- Must be able to sit for prolonged periods of time in an office setting
- Ability to use office equipment
Working Conditions - General office environment
- Minimal travel requirement
- May work remote up to 40% of the time
Minimum Qualifications - Bachelor's degree in behavioral health, social work, psychology, healthcare administration, human services, or a related field required; master's degree preferred
- Minimum of 3 to 5 years of experience in quality improvement, quality assurance, compliance, or clinical operations, preferably in behavioral health or child serving programs
- Demonstrated knowledge of HIPAA privacy, security, and breach notification requirements, behavioral health regulations, clinical documentation standards, and quality improvement methodologies
- Experience with audits, performance data, corrective action plans, and regulatory or accreditation reviews, preferably with COA and CDHS
- Strong analytical, organizational, communication, leadership, and problem-solving skills
- Ability to collaborate effectively with multidisciplinary teams, support staff development, and manage confidential information with discretion
- Preferred: Experience serving children, adolescents, and families in behavioral health settings
- Preferred: Supervisory experience, and a professional certification such as CHC, CPHQ, or CHPC
- All candidates must have (or qualify to obtain) a current Colorado driver's license
- All positions require a pre-employment drug test, FBI fingerprint check, CBI criminal records check, child abuse registry check, motor vehicle record check, academic record verification, and reference checks
Benefits For employees working 30 or more hours per week:
- Medical, Dental, & Vision Insurance options
- Generous Paid Time Off
- 13 paid holidays
- Paid Mental Health days to regroup & recharge
- Retirement Plan with a match up to 4% of your annual salary
- Pet, Legal & Identity Theft insurance options
- HSA & FSA options
- Accident, Critical Illness, Disability & Hospital Indemnity insurance options
- Company paid Life Insurance & AD&D with options to purchase additional coverage
- Employee Assistance Program
- Employee Referral Bonus
- Professional Development Assistance
- Some positions may qualify for the Public Service Loan Forgiveness Program. For more information, go to https://www.colorado.gov/pacific/dhr/student-loan-forgiveness-programs
The estimated salary for this role is $115,000.00 - $120,000.00 annually.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
