Director of Compliance and Quality Improvement

Katie Blessing Center•Charlotte, NC

68d•Onsite

About The Position

As the Director of Compliance and Quality Improvement at Katie Blessing Center, you will play a pivotal, high-impact role driving the operational launch, regulatory readiness, corporate ethics, and clinical quality standards of our new hospital. As a key member of the KBC team, this role will have significant responsibility during the pre-opening phase. You will develop and implement the hospital’s regulatory and accreditation readiness strategy, build core quality, compliance, risk, patient safety, and privacy programs, and ensure required processes are fully operational before the hospital opens its doors and undergoes licensure and accreditation surveys. In this hands-on, working director role, you won’t just audit processes – you will build the culture. You will establish and execute our Quality Assessment and Performance Improvement (QAPI) plan, Enterprise Risk framework, Patient Safety Program, and Corporate Compliance/Privacy safeguards (HIPAA / 42 CFR Part 2). You will champion a Just Culture of non-retaliatory reporting, drive continuous survey readiness, and ensure total alignment with CMS Conditions of Participation, The Joint Commission standards, and North Carolina regulatory requirements.

Requirements

Bachelor’s degree in Nursing, Healthcare Administration, Quality, Public Health, or a related healthcare field.
Minimum of five (5) years of healthcare experience, including at least three (3) years of progressive leadership experience in quality, compliance, risk management, regulatory readiness, or performance improvement in a hospital setting.
Demonstrated knowledge of QAPI frameworks, event investigation (RCA/FMEA), data interpretation, dashboard development, and regulatory readiness.

Nice To Haves

Master's degree in Healthcare Administration, Public Health, Nursing, Quality, Business, or a related field.
Registered Nurse (RN) with current North Carolina or compact-state licensure.
3+ years in an inpatient psychiatric hospital, acute care, or pediatric behavioral health setting.
Hands-on experience preparing for and managing Joint Commission and CMS hospital survey processes.
Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Certified Professional in Patient Safety (CPPS).
Direct experience with facility startups, opening a new hospital, or designing a QAPI/Compliance program from the ground up.

Responsibilities

Develop, execute, and evaluate the hospital’s annual QAPI Plan. Establish meaningful clinical, operational, and patient-experience indicators, build executive dashboards, and lead multidisciplinary teams using structured PI methodologies (PDSA, Lean).
Manage the hospital’s Corporate Compliance Program in accordance with OIG guidelines. Oversee the anonymous hotline, investigate ethics/FWA allegations, enforce HIPAA and 42 CFR Part 2 privacy standards, and manage monthly OIG/SAM exclusion screenings.
Lead patient safety initiatives tailored to pediatric psychiatric care—including ligature-risk mitigation, suicide/self-harm prevention, elopement reduction, and restraint/seclusion reduction. Oversee incident triage, RCAs, FMEAs, and Sentinel Event reporting while maintaining the Enterprise Risk Register.
Partner with Utilization Review (UR) and HIM to establish compliance audit schedules for medical necessity (mitigating Medicaid recoupment risks). Oversee institutional compliance with North Carolina Involuntary Commitment (IVC) legal hold statutes and mandatory Child Protective Services (CPS) reporting laws.
Lead continuous survey readiness for CMS, The Joint Commission, and the NC Division of Health Service Regulation (DHSR)—directing mock tracers, gap assessments, and real-time survey operations.
Translate quality, safety, and compliance data into actionable reports for Executive Leadership, the Medical Executive Committee, and the Governing Board.