Clinical Department Manager - Quality Assurance (TUC- Strength United) (Internal)

California State University, Northridge•Northridge, CA

10d•Hybrid

About The Position

The University Corporation is a non-profit auxiliary corporation providing commercial and administrative services to California State University, Northridge. Our mission is to provide services and solutions that address the needs of California State University, Northridge; to support the academic, research, and creative endeavors of its students, faculty, and staff; and to enhance the quality of campus life. Mission: Transforming trauma and violence into empowerment, advancing systemic healing, and developing leaders for lasting change. Overview: Reporting to the Director of Programs, the Clinical Department Manager - Quality Assurance is responsible for ensuring agency-wide clinical compliance, quality assurance, and documentation standards across all Strength United programs. This position develops and implements clinical standards, conducts compliance audits, and optimizes electronic health record (EHR) systems. The Clinical Department Manager, in coordination with the other CDMs ensures that all clinical staff, volunteers, and trainees adhere to organizational policies, professional ethical standards, and regulatory requirements. This position plays a critical role in maintaining the quality and integrity of clinical services across the organization through systematic monitoring, training, and continuous improvement initiatives. The Clinical Department Manager ensures that Strength United’s values and workplace culture are present in all compliance and quality assurance activities.

Requirements

Master's degree from an accredited institution in Marriage and Family Therapy or Clinical Social Work.
Current, active California (CA) license (LMFT or LCSW), and meets the CA Board of Behavioral Sciences requirements to provide clinical supervision to graduate students obtaining hours toward CA licensure.
Completed training in Trauma Informed Cognitive Behavioral Therapy, Cognitive Processing Therapy, and Seeking Safety.
Minimum of three years' post-licensure clinical experience providing services to survivors of child maltreatment, sexual assault, and domestic violence.
Strong knowledge of BBS regulations, HIPAA requirements, and professional ethical standards.
Experience with electronic health record systems required.
Solid management experience including strong organizational, delegation, and communication skills.
Strong supervisory background.
Computer competency, including Word, Excel, Outlook, PowerPoint, and data analysis tools.
Minimum of three years’ clinical and supervisory experience providing services to individuals of all ages who have experienced child maltreatment, sexual assault, domestic violence, poly-victimization and high risk (suicidal/co-occurring) clients.
Experience with crisis intervention, family systems, and biopsychosocial assessment.
Ability to analyze complex situations accurately and adopt effective courses of action.
Ability to supervise staff, student trainees and volunteers individually and in groups on complex matters when needed.
Ability to determine appropriate courses of action and proper techniques to utilize while engaged with individuals in interactions of a sensitive nature.
Ability to interpret and evaluate descriptions and explanations of problems.
Strong clinical skills and practice orientation in trauma informed care, relational supervision and student-professional development.
Excellent written and communication skills.
Ability and specialized skills to organize, coordinate, and prioritize multiple tasks.
Ability to work independently in a busy environment with frequent interruptions and changing priorities.
Ability to maintain cooperative working relationships with others.
Team oriented.
Ability to coordinate/collaborate with professionals from multiple agencies while maintaining appropriate boundaries and client confidentiality.
Passion and sensitivity for trauma work.
Demonstrate an acceptance and respect for cultural diversity in all its forms, including ethnicity, sexual orientation.
Must possess a reliable vehicle, valid California Driver’s license and proof of automobile insurance.
Must Maintain personal cell phone.

Nice To Haves

Experience with clinical quality assurance, compliance monitoring, or auditing preferred.
Exym experience preferred.

Responsibilities

Oversee agency-wide clinical compliance and quality assurance across all Strength United Intervention programs (Mental Health, Access to Care/MDT, Family Preservation).
Develop and implement compliance monitoring systems and quality improvement initiatives.
Monitor organizational compliance with professional standards, regulatory requirements, and organizational policies.
Participate in required meetings with program managers and leadership to address compliance trends and quality concerns.
Collaborate with program managers to ensure consistent application of clinical standards while respecting program-specific requirements.
Provide guidance and support to clinical supervisors across all programs on complex supervision matters and compliance questions.
Serve as a resource for clinical staff on documentation standards, ethical guidelines, and professional requirements.
Collaborate with program managers to address personnel performance issues related to clinical documentation or compliance.
May provide backup clinical supervision coverage in emergency situations when coordinated through the Senior Director of Programs.
Ensure adherence to agency policies, procedures, and professional ethical guidelines across all clinical programs.
Conduct monthly clinical compliance audits across all programs with detailed findings and recommendations.
Review progress notes, treatment plans, and clinical records for accuracy, timeliness, and quality.
Ensure signatures and documentation meet required timelines per organizational policy (24-hour crisis response, documentation review, and RFS submission).
Verify documentation standards are maintained by program type and funding source.
Submit compliance audit reports to Senior Director of Programs with trends, concerns, and improvement strategies.
Monitor quality standards for client intake processes across programs.
Identify patterns of non-compliance and develop corrective action plans.
Analyze compliance audit data to identify trends and systemic issues.
Track improvement over time through quarterly comparative analysis.
Participate in agency quality assurance meetings, utilization review meetings, and program evaluation activities as assigned.
Designated SU HIPAA Privacy Officer.
Develop and deliver agency-wide training on documentation standards and compliance requirements.
Train all clinical staff and volunteers on clinical protocols, ethical standards, and regulatory requirements.
Deliver compliance training to clinical supervisors and clinicians across all programs.
Ensure consistent application of clinical protocols organization wide.
Train all clinical staff on new or updated standards within 120 days of implementation.
Provide ongoing refresher trainings and targeted training based on audit findings.
Develop agency-wide clinical supervision standards applicable across all programs.
Create clinical documentation protocols and best practice guidelines.
Establish benchmarks for clinical quality across all Strength United programs.
Document standards in clear, accessible formats and ensure distribution agency-wide within 90 days.
Develop standardized templates, checklists, and tools to support clinical compliance.
Update standards regularly reflect changes in regulations, best practices, and organizational needs.
Coordinate with external regulatory bodies and professional organizations to stay current with compliance requirements.
Represent Strength United in professional forums related to clinical standards and quality assurance.
Collaborate across all programs to deliver high performing services while meeting confidentiality standards.
Review Exym system usage and functionality across all programs.
Identify opportunities to maximize EHR effectiveness and efficiency.
Monitor staff and volunteer compliance with documentation deadlines outlined in policies.
Analyze EHR data to identify documentation bottlenecks and workflow issues.
Recommend system improvements and workflow enhancements to leadership.
Complete quarterly Exym utilization reports with data analysis and recommendations.
Collaborate with IT and program managers to implement EHR improvements.
Monitor that clinical programs maintain documentation standards required for billing and reimbursement.
Collaborate with program managers to ensure grant deliverables related to clinical quality are met.
Embody and model Strength United’s mission, values, and organizational culture in all compliance and quality assurance activities.
Lead with courage, authenticity, and integrity, fostering workplace culture that promotes excellence, accountability, and continuous improvement.
Act as a steward of clinical quality and organizational integrity, holding self and the organization accountable to standards of excellence and ethical practice.
Approach compliance monitoring with a spirit of support and continuous improvement rather than punitive oversight.
Make decisions through the lens of organizational values, balancing client care, staff wellbeing, and regulatory requirements.
Serve as a culture carrier for clinical excellence, demonstrating commitment to high-quality, trauma-informed care across all programs.
Perform duties in a highly professional manner, advancing the organization's mission and reputation in the clinical community.
Other duties as assigned.