POSITION TITLE: Vice President of Quality Assurance and Compliance

FLSA STATUS: Exempt

REPORTS TO: President & Chief Executive Officer and Chief Clinical Officer

POSITION SUMMARY

The Vice President of Quality Assurance and Compliance serves as a senior executive leader responsible for advancing organizational excellence, regulatory compliance, patient safety, accreditation readiness, risk management, and continuous quality improvement across Lifeline Connections' behavioral health programs and operations. This position partners closely with the Chief Executive Officer and Executive Leadership Team to develop and implement enterprise-wide strategies that promote clinical quality, operational integrity, compliance with applicable federal and state regulations, and measurable organizational outcomes. The Vice President leads initiatives related to CARF and CCBHC accreditation, regulatory oversight, quality assurance, incident management, performance improvement, workforce competency development, and evidence-based practice fidelity. The incumbent promotes a culture of ethical practice, transparency, accountability, trauma-informed care, continuous learning, and person-centered service delivery.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Executive Leadership & Organizational Strategy

1. Serves as a strategic executive advisor to the CEO and Executive Leadership Team regarding quality improvement, compliance, accreditation, patient safety, and organizational risk management.
2. Collaborates with CEO and executive leadership in agency strategic planning, operational planning, workforce development, and organizational performance improvement initiatives.
3. Provides leadership in developing a culture focused on continuous quality improvement, compliance, ethical decision-making, and service excellence.
4. Participates in organizational planning related to value-based payment models, quality outcomes, utilization management, and operational performance metrics.

Regulatory Compliance & Accreditation

1. Ensures organizational compliance with applicable:

• Washington Administrative Codes (WAC)
• Revised Code of Washington (RCW)
• Oregon Revised Statuses (ORS)
• Oregon Administrative Rules (OAR)
• Department of Health (DOH) regulations
• Department of Social and Health Services (DSHS) requirements
• Centers for Medicare & Medicaid Services (CMS) standards
• OSHA regulations
• HIPAA Privacy and Security Rules
• 42 CFR Part 2 confidentiality requirements
• CARF and CCBHC accreditation standards
• Other applicable federal, state, neighboring state(s), and local behavioral health regulations

1. Maintains organizational readiness for CARF surveys, CCBHC requirements, DOH licensing reviews, Medicaid audits, and other regulatory or accreditation inspections.
2. Oversees organizational corrective action planning related to audit findings, incidents, grievances, compliance deficiencies, and accreditation recommendations.
3. Serves as the organization's Compliance and Privacy Officer overseeing the organization's compliance and privacy reporting processes.

Quality Assurance & Performance Improvement

1. Develops, implements, and oversees organization-wide quality assurance and performance improvement systems.
2. Establishes measurable quality indicators, performance metrics, and treatment outcome monitoring systems across programs and departments.
3. Oversees the collection, analysis, interpretation, and reporting of organizational quality and compliance data.
4. Leads and successfully implements continuous quality improvement initiatives focused on patient outcomes, patient safety, access to care, service effectiveness, compliance, and operational efficiency.
5. Ensures fidelity to evidence-based and promising practices through monitoring, auditing, coaching, and staff development activities.
6. Staffs the organization's Quality Assurance and Performance Improvement Committee and provides quarterly quality and compliance reports to executive leadership and the Board of Directors.

Risk Management & Patient Safety

1. Oversees organizational risk management activities, including:

• Incident reporting
• Sentinel event review
• Root cause analysis
• Corrective action implementation
• Patient grievance processes
• Patient feedback processes
• Compliance investigations
• Patient safety initiatives

1. Identifies clinical, operational, financial, and compliance-related risks and develops mitigation strategies.
2. Ensures appropriate response protocols are implemented for regulatory incidents, patient complaints, adverse events, and compliance concerns.

Policy Development & Operational Oversight

1. In conjunction with CEO and executive team, develops, reviews, updates, and implements organizational policies, procedures, and compliance protocols consistent with regulatory and accreditation standards.
2. Provides oversight of assigned departments, including quality assurance, records management, electronic health records, compliance functions, and other assigned operational areas.
3. Supports the development and implementation of new programs, workflows, and operational processes related to quality assurance and compliance.
4. Ensures documentation systems and recordkeeping practices meet organizational, regulatory, payer, and accreditation standards.

Workforce Development & Competency Management

1. Develops and oversees competency-based staff development systems consistent with CARF and CCBHC standards and organizational needs.
2. Leads staff education and training initiatives related to:

• Compliance
• HIPAA
• Patient safety
• Documentation standards
• Incident reporting
• Quality improvement
• Evidence-based practices
• Ethical conduct
• Accreditation

1. Supervises assigned staff and leaders, including performance management, coaching, corrective action, and professional development activities.
2. Supports leadership development, succession planning, and workforce competency assessment processes.

Community & Organizational Representation

1. Represents Lifeline Connections with regulatory agencies, accrediting bodies, community partners, external auditors, and stakeholders.
2. Serves as staff support to assigned Board Committees and provides formal reports and presentations as requested by CEO.
3. Participates in after-hours consultation and executive response activities as needed.
4. Performs other duties as assigned.

Core Competencies

The successful candidate will demonstrate proficiency in the following areas:

• Strategic Leadership
• Regulatory Compliance Expertise
• CARF and CCBHC Accreditation Readiness
• Risk Management
• Continuous Quality Improvement
• Data Analytics & Outcome Measurement
• Executive Communication & Competencies
• Ethical Decision-Making
• Trauma-Informed Leadership
• Change Management
• Policy Development
• Workforce Development
• Operational Excellence
• Interdisciplinary Collaboration
• Problem Solving & Critical Thinking
• Cultural Humility & Inclusive Leadership

MINIMUM QUALIFICATIONS

1. Master's degree in Behavioral Health, Healthcare Administration, Social Work, Counseling, Public Health, Nursing, Psychology, or related field required.
2. Minimum of five (5) years of progressive leadership experience in behavioral health quality assurance, compliance, risk management, accreditation, or healthcare operations required.
3. Minimum of three (3) years of supervisory or executive leadership experience in a behavioral health or healthcare setting required.
4. Demonstrated experience with:

• CARF accreditation
• CCBHC demonstration and/or certification
• Regulatory audits
• Quality improvement systems
• Incident management
• Compliance investigations
• Policy development
• Performance improvement initiatives

1. Knowledge of:

• WAC 246-341
• RCW 71.24
• HIPAA
• 42 CFR Part 2
• CMS requirements
• CARF and CCBHC requirements
• Behavioral health licensing standards
• Medicaid documentation requirements

1. Ability to analyze organizational data, develop performance metrics and key performance indicators, and lead corrective action initiatives.
2. Strong written, verbal, presentation, and executive communication skills.

PREFERRED QUALIFICATIONS

• Licensed Mental Health Professional (LMHC, LICSW, LMFT, PsyD, PhD, RN, etc.)
• Mental Health Professional (MHP) designation consistent with WAC 246-341
• Certified Professional in Healthcare Risk Management (CPHRM)
• Certified Professional in Patient Safety (CPPS)
• Certified in Healthcare Compliance (CHC)
• Lean/Six Sigma training or certification
• Experience serving in a Compliance Officer role
• Experience in value-based care environments
• Experience leading CARF surveys or accreditation readiness activities
• Experience leading CCBHC implementation, accreditation, or readiness activities

Salary: $100,000 - $120,000 / year Dependent on Experience

Application Process:
To apply electronically for this position, please click "Apply Now" or visit our ADP career center. For more information on this and other positions, please visit our website at www.lifelineconnections.org

The Benefits:

Lifeline Connections strives to be an employer of choice by offering regular and full-time employees a robust and highly competitive benefits package designed to support both personal and family well-being. Our comprehensive benefits include multiple options for medical, dental, and vision coverage for employees and their eligible dependents.

In addition, Lifeline Connections provides employer-paid Short Term Disability, Long Term Disability, and Life Insurance, along with access to supplemental coverage options. Full-time employees and eligible part-time employees may also enroll in our 401(k) retirement plan, helping support long-term financial wellness.

Beyond benefits coverage, Lifeline Connections is proud to offer generous paid time off. Both full-time and part-time employees earn PTO at competitive accrual rates that increase with years of service, allowing for meaningful time away from work. Employees also receive paid holidays and personal holidays, reinforcing our commitment to work-life balance and employee well-being.