Director of Continuous Quality Improvement

Valley Cities Behavioral Health CareFederal Way, WA
Onsite

About The Position

Valley Cities has been selected to lead efforts in Washington State to become a Certified Community Behavioral Health Clinic (CCBHC), reflecting compliance with stringent national standards in behavioral health care. This status enables broader service availability, improved integration of mental health and substance use treatment, enhanced crisis intervention capabilities, and ensures services are accessible to all, regardless of financial circumstances. The Director of Continuous Quality Improvement (CQI) provides agency-wide leadership for Valley Cities Behavioral Health Care's quality improvement, performance measurement, and outcomes management functions across all outpatient, residential, and community programs. The Director designs, implements, and maintains the agency's Continuous Quality Improvement Plan; leads data-driven improvement initiatives; and ensures quality activities meet the requirements of federal, state, and payer regulations, accreditation standards, and contractual obligations. As a member of the agency's leadership team, the Director plays a central role in Valley Cities' Certified Community Behavioral Health Clinic (CCBHC) certification and ongoing compliance, with primary responsibility for the CQI plan and quality reporting obligations established under CCBHC program requirements. The Director partners closely with Compliance and Risk Management, Clinical Leadership, Business Intelligence & Analytics, Information Technology, and Human Resources to embed a culture of continuous improvement, safety, and accountability throughout the organization.

Requirements

  • Master's degree in public health, health administration, behavioral health, nursing, social work, or a related field; or an equivalent combination of education and experience.
  • Five (5) or more years of progressively responsible experience in quality improvement, performance measurement, or compliance within a behavioral health, healthcare, or community-based human services setting.
  • Two (2) or more years of supervisory or program leadership experience.
  • Demonstrated knowledge of CQI methodologies (e.g., PDSA, Lean, root cause analysis) and healthcare quality measurement.
  • Working knowledge of behavioral health regulatory and payer environments, including Medicaid, managed care, and Washington State licensing requirements (or the ability to acquire such knowledge rapidly).
  • Must pass a criminal background check in accordance with agency policy and applicable law.

Nice To Haves

  • Direct experience with CCBHC certification, demonstration, or expansion grant programs, including CCBHC quality measure reporting.
  • Experience with accreditation processes (The Joint Commission or CARF).
  • Project Management Professional, Certified Professional in Healthcare Quality (CPHQ), or comparable quality certification.
  • Experience with electronic health record systems, data analytics and visualization tools, and quality reporting platforms.
  • Experience working in a nonprofit, multi-site behavioral health organization.

Responsibilities

  • Develop, implement, and annually update the agency-wide Continuous Quality Improvement Plan, ensuring alignment with the agency's mission, vison and strategic plan, and applicable regulatory and accreditation requirements.
  • Chair and provide staff leadership to the agency CQI Committee, including agenda development, action tracking, and reporting of committee outcomes to executive leadership and the Board of Directors.
  • Lead structured improvement initiatives using recognized methodologies (e.g., Plan-Do-Study-Act cycles, root cause analysis, process mapping) across clinical and administrative operations.
  • Establish, monitor, and report key performance indicators (KPIs) for access, engagement, clinical outcomes, safety, client experience, and operational performance across all sites.
  • Oversee client satisfaction and experience-of-care surveys, grievance trend analysis, and integration of client and family voice into improvement activities.
  • Coordinate quality-related components of accreditation readiness and ongoing conformance (e.g., The Joint Commission or CARF), including standards crosswalks, mock surveys, and corrective action plans.
  • Collaborate with the Director of Compliance and Risk Management on incident reporting trends, sentinel/adverse event reviews, mortality reviews, and follow-up on corrective and preventive actions.
  • Partner with Business Intelligence & Analytics, IT and data teams to develop dashboards, data validation processes, and reporting infrastructure that support timely, accurate performance measurement.
  • Provide training, coaching, and technical assistance to program leaders and staff on quality improvement principles, data literacy, and outcome measurement.
  • Partner and develop CCBHC quality and reporting requirements, ensuring Valley Cities develops, implements, and maintains a CCBHC Continuous Quality Improvement Plan that meets SAMHSA CCBHC Certification Criteria, Program Requirement 5, and Washington State Health Care Authority (HCA) expectations.
  • Oversee accurate and timely collection, validation, and submission of required CCBHC quality measures, including clinic-collected measures and coordination with the state on state-collected measures.
  • Participate as an active member of the CCBHC implementation team, contributing to certification readiness activities, gap analysis remediation, site visit preparation, and ongoing attestation and recertification processes.
  • Hire, train, supervise, and evaluate assigned quality department staff in accordance with agency policy.
  • Develop and maintain policies and procedures related to quality improvement, outcomes measurement, and reporting.
  • Represent Valley Cities in external quality collaboratives, payer quality meetings, and state or regional workgroups as assigned.
  • Perform other duties as assigned in support of agency operations and strategic priorities.

Benefits

  • Medical, Dental, & Vision coverage available for employees and eligible family members and dependents
  • Health Savings Account, $2,000 contribution annually, prorated monthly.
  • Agency sponsored retirement plan, up to 6% employer contributions, and pre-tax/Roth available
  • Access to Employee Assistance Program (EAP) resources
  • Comprehensive paid time off, paid holidays, and extended sick leave options
  • Access to Student Loan Forgiveness Programs
  • Annual longevity bonuses
  • Recognition programs and incentives
  • Access to training, supervision, and consultation for professional certification and licensure
  • Clinical supervision provided toward licensure, if applicable
  • Paid training days and yearly training fund
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