Director Quality, Risk, and Compliance- Behavioral Health | The Pavilion at Williamsburg Place | Williamsburg, Virginia
About the Job:PURPOSE STATEMENT:
The Director of Quality, Risk & Compliance leads and coordinates quality and performance improvement, regulatory compliance, and patient safety efforts within the healthcare facility. This role ensures that all programs operate within local, state, federal, and accreditation standards, while driving a culture of continuous improvement, clinical excellence, and risk reduction.
Roles and Responsibilities:ESSENTIAL FUNCTIONS:- Provides oversight of all facility programs, including inpatient and outpatient services, ensuring alignment with quality, risk management, patient safety, and regulatory standards.
- Leads facility-wide quality, risk, and patient safety strategy and improvement efforts.
- Directs the Quality Assurance/Performance Improvement (QAPI) program, including development, implementation, and evaluation; monitors KPIs and ensures governance of data-driven improvement efforts.
- Drives organization-wide performance improvement initiatives through data analysis and system-level process enhancements to improve outcomes.
- Oversees incident reporting, investigations, and risk analyses (RCA/Event Analysis), ensuring timely resolution and prevention of recurrence.
- Maintains compliance with all local, state, federal (CMS), and accreditation standards (TJC), ensures ongoing survey readiness, and serves as the primary liaison during regulatory and accreditation surveys, audits, and required reporting activities.
- Partners with the Legal, Compliance, and Risk Department on high-risk events, complaints/allegations, investigations, and corrective action planning.
- Supports the development, review, and implementation of facility policies and procedures, ensuring alignment with regulatory requirements and consistent adherence across departments.
- Collaborates with department leaders and Human Resources to support staff accountability and ensure adherence to facility policies and procedures.
- Provides staff training and mentoring to support competency, accountability, and adherence to quality, risk, and safety standards, while fostering a culture of continuous improvement and patient safety.
- Conducts leadership rounding, medical record reviews, and monitoring of environment of care, safety, and documentation standards.
- Prepares and maintains required reports and documentation; participates in committees, meetings, audits, and organizational initiatives.
- Supervises Patient Advocate/Coordinator roles, when applicable, through hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department and facility goals. Supports resolution of patient concerns and patient rights processes.
- Serves as Patient Safety and Compliance Officer, providing oversight of patient safety, risk management, and event reporting processes within organizational governance structures.
- Serves as Patient Safety and Compliance Officer, providing oversight of client safety, risk management, and event reporting processes within organizational governance structures.
- May serve as Privacy/Security Officer, providing direction and oversight of activities related to compliance with applicable Federal and State law and regulations governing the privacy and security of health information.
- May serve as Chief Healthcare Disparities Officer, leading efforts to identify, analyze, and reduce disparities in care for the populations served.
- May be required to provide onsite coverage for other programs when needed, develops, and executes new programs according to market needs and may provide training, case consultation and Administrator On Call coverage during and after program hours as needed.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: - Bachelor's degree with a clinical, nursing or business emphasis required. Master's degree in Human Services preferred.
- Three years' experience in quality, patient safety, regulatory compliance, risk management, survey management, behavioral health, substance use disorder treatment, or related experience required.
- Knowledge and understanding of state/federal regulations, Joint Commission and/or CARF Accreditation.
LICENSES/DESIGNATIONS/CERTIFICATIONS:- CPHQ Preferred
- Professional clinical license issued by the appropriate licensing body as required by the state.
- CPR and de-escalation and restraint certification required (training available upon hire and offered by facility).
- First aid may be required based on state or facility
WORK LOCATION:This position is onsite at the facility and is not a remote position.
SUPERVISORY REQUIREMENTS: Two years' supervisory/management experience in behavioral health preferred.
