Director of Quality Assurance & Compliance

Description

Under the direction of the CEO, the Director of Quality Assurance & Compliance provides executive leadership for the agency’s quality improvement, accreditation, regulatory compliance, and risk management activities. This role ensures the organization maintains compliance with COA accreditation standards, licensing requirements, contract obligations (including Medicaid where applicable), HIPAA regulations, and other governing requirements. The Director works closely with program leadership to strengthen documentation standards, monitor program performance, improve internal systems, and support a culture of continuous quality improvement across the organization. 

CORE RESPONSIBILITIES

Quality Assurance & Performance Improvement

• Lead the collection, monitoring, and analysis of program outcome data in alignment with quality improvement policies and accreditation standards.
• Collaborate with program managers and directors to ensure consistent and accurate data collection.
• Conduct quality checks within agency systems and develop performance reports.
• Identify trends, risks, and performance gaps and recommend corrective actions.
• Ensure programs align with the agency’s strategic plan through measurable outcomes.
• Communicate emerging compliance or performance concerns to senior leadership.
• Organizational growth and expansion within Family Centered Services (FCS) may require shifting priorities, evolving data and reporting expectations, and modifications to duties as operational needs develop.

Accreditation, Licensure & Regulatory Compliance

• Oversee ongoing compliance with COA accreditation standards and licensing requirements.
• Ensure adherence to HIPAA, confidentiality regulations, and documentation standards.
• Conduct internal audits and compliance reviews.
• Prepare required reports for accrediting bodies, licensing entities, and regulatory agencies.
• Monitor compliance with contractual requirements including Medicaid and other funding sources.
• Develop and implement corrective action plans when compliance issues are identified.

Policy Management & Governance

• Maintain official copies of all agency policies and procedures.
• Coordinate the agency’s structured four-year policy review cycle.
• Collaborate with senior leadership and the Governance Committee to review and revise policies.
• Present policy updates for Board approval.
• Ensure policies align with regulatory, accreditation, and licensing standards.
• Provide guidance to leadership on policy implementation.

Data Analytics & Organizational Reporting

• Develop dashboards and reporting systems to monitor quality and compliance metrics.
• Present regular quality and compliance updates to the Board of Directors.
• Provide outcome data for grant reporting, annual reports, and organizational communications.
• Use data analysis to evaluate program effectiveness and identify improvement opportunities.
• Conduct and analyze client satisfaction surveys across programs.

Risk Management & Incident Oversight

• Oversee the agency’s critical incident reporting processes.
• Ensure timely reporting to licensing and accrediting bodies.
• Monitor incident trends and recommend preventive or corrective actions.
• Promote best practices to reduce organizational risk exposure.

Training & Organizational Support

• Provide training and consultation to staff on:
  • Quality improvement practices
  • Accreditation standards
  • Compliance and regulatory requirements
  • Documentation expectations
  • Incident reporting procedures
  • Process improvement methods
• Serve as a resource to program leaders regarding regulatory interpretation and compliance best practices.
• Promote a culture of accountability, learning, and continuous improvement.

Leadership Expectations

• Participate in community and professional meetings that strengthen collaboration with partner organizations.
• Model integrity, accountability, and sound judgment in all decision-making.
• Work collaboratively with program leadership to strengthen organizational outcomes.
• Balance compliance oversight with supportive consultation and problem-solving.

Requirements

EDUCATION AND EXPERIENCE

Required

• Bachelor’s degree in health, human services, public administration, or a related field.
• Minimum three years of experience in quality assurance, quality improvement, or regulatory compliance.
• Experience working in health or human services settings.
• Familiarity with Medicaid processes and contract compliance.

Preferred

• Master’s degree in social work, public health, healthcare administration, or related field.
• Experience with COA accreditation standards.
• Experience conducting internal audits or accreditation reviews.
• Technical writing experience.
• Experience training staff on data collection and compliance practices.

Skills & Competencies· 

• Knowledge of accreditation, licensing, regulatory frameworks, and the ability to interpret policies, contracts, and governmental regulations.
• Strong analytical, data interpretation, and problem-solving skills with the ability to develop defensible conclusions.
• Technical writing, reporting, and presentation skills suitable for executive and Board-level audiences.
• Strong organizational and project management abilities with attention to detail and commitment to accuracy.
• Effective interpersonal, communication, and collaboration skills

Computer & Technical Skills

• Proficiency in Microsoft Office Suite, and an ability to work with agency databases and reporting systems.
• Experience with statistical or data analysis tools (such as SPSS or similar software).
• Strong data management and reporting skills.

Special Requirements

• Must complete all required training related to licensing, accreditation, contracts, and agency standards.
• Valid driver’s license, proof of insurance, and reliable transportation required.
• Occasional travel may be required.

Be a part of something extraordinary!

We are proud to be an Equal Opportunity employer. Qualified applicants will receive consideration for employment without regard to race, sex, disability, veteran, or other protected status.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.