Director of Quality Improvement & Privacy

Tennyson Center for Children•Denver, CO

3d•Hybrid

About The Position

The Director of Quality Improvement and Privacy leads Tennyson Center for Children’s organization-wide quality improvement program, encompassing compliance, risk management, outcome evaluation, accreditation, policy management, and privacy. The role ensures compliance with applicable state and federal regulations, licensing requirements, accreditation standards, and payer contracts, while promoting safety, continuous learning, trauma-informed care, and family-centered services. The Director serves as the designated Privacy Officer and PolicyTech system administrator, and supervises the Health Record Analyst. The role partners with the Electronic Health Record Administrator and the Chief Financial and Operations Officer on health information management, data integrity, audit findings, and privacy requirements. The position may work remotely up to 40% of the time and is based in a general office environment with minimal travel.

Requirements

Bachelor’s degree in behavioral health, social work, psychology, healthcare administration, human services, or a related field.
Three to five years of experience in quality improvement, quality assurance, compliance, or clinical operations.
Demonstrated knowledge of HIPAA privacy, security, and breach notification requirements, behavioral health regulations, clinical documentation standards, and quality improvement methodologies.
Experience with audits, performance data, corrective action plans, and regulatory or accreditation reviews.
Strong analytical, organizational, communication, leadership, and problem-solving skills.
Ability to collaborate effectively with multidisciplinary teams, support staff development, and manage confidential information with discretion.
Must have or qualify to obtain a current Colorado driver’s license.
Must complete required pre-employment checks, including drug testing, FBI fingerprint check, CBI criminal records check, child abuse registry check, motor vehicle record check, academic record verification, and reference checks.
Must demonstrate eligibility to work in the United States; the employer does not sponsor work visas.

Nice To Haves

Master’s degree.
Experience in behavioral health or child-serving programs.
Experience with COA and CDHS accreditation or regulatory reviews.
Experience serving children, adolescents, and families in behavioral health settings.
Supervisory experience.
Professional certification such as CHC, CPHQ, or CHPC.

Responsibilities

Develop and manage the compliance program, including policies and reviews, to support compliance with regulations, licensing requirements, accreditation standards, payer contracts, and applicable CDHS and CDE requirements, FERPA, and IDEA.
Lead the Council on Accreditation (COA) accreditation process and annual CDHS licensing process, and maintain ongoing readiness across programs.
Lead CDHS TRAILS reporting and background checks; coordinate timely responses to CDHS Reports of Investigations; maintain regulatory relationships; and recommend investigative procedures when violations are alleged.
Serve as an accreditation and licensing subject matter expert, communicate readiness and gaps to executive leaders, and partner with department directors on corrective plans.
Administer the risk management program with the Chief Financial and Operations Officer, covering adverse events, client rights and grievances, safety, and media and reputational risks.
Oversee incident reporting, grievance tracking, and investigations; review critical incidents and reportable events for timeliness, regulatory compliance, and appropriate trauma-informed interventions.
Identify risk trends and root causes, recommend preventive actions, and escalate significant safety, privacy, or compliance concerns.
Develop and deliver onboarding and annual staff training on risk management, compliance, audits, privacy and HIPAA, quality standards, documentation, and client rights; assess staff knowledge in partnership with Human Resources.
Gather, validate, and report quality improvement and risk management data, including key performance indicators, on monthly, quarterly, and annual schedules.
Lead development of organizational dashboards, monitor clinical outcomes and strategic plan progress, and communicate results to leadership.
Prepare quality reports and impact presentations for leadership, committees, the Board of Directors, and marketing and development.
Develop and oversee the organization’s quality and performance improvement program using a closed-loop Continuous Quality Improvement approach across programs.
Lead improvement initiatives addressing client safety, treatment effectiveness, family engagement, and youth outcomes, including restraint use, elopements, timely reporting of abuse and neglect allegations, record audits, and staff retention.
Develop and monitor performance indicators, corrective action plans, and improvement goals; conduct internal audits and chart reviews as appropriate.
Review quarterly SmartCare audits conducted by the Electronic Health Record Administrator and recommend corrective actions.
Collaborate with clinical and executive leadership to include new programs in the CQI process, promote accurate data collection, and support continuous improvement.
Administer PolicyTech, including periodic policy review, approval, and version control; work with policy owners to update policies based on regulatory changes, audit findings, and incident trends; oversee forms management and document control.
Serve as Privacy Officer, overseeing privacy issues involving health records, security, breach notifications, HITECH, FERPA, and IDEA; maintain privacy policies, procedures, and notices and coordinate privacy-related technology and security safeguards.
Investigate suspected privacy violations and breaches of unsecured PHI, ensure required notifications are completed on time, coordinate privacy complaints and risk assessments, and document investigations and corrective actions.
Supervise, coach, and evaluate the Health Record Analyst, and partner with the Electronic Health Record Administrator and Chief Financial and Operations Officer on health information management and data integrity.
Perform other duties as assigned.

Benefits

Medical, dental, and vision insurance options for employees working 30 or more hours per week.
Generous paid time off.
13 paid holidays.
Paid mental health days.
Retirement plan with a match up to 4% of annual salary.
Pet, legal, and identity theft insurance options.
HSA and FSA options.
Accident, critical illness, disability, and hospital indemnity insurance options.
Company-paid life insurance and AD&D, with options to purchase additional coverage.
Employee Assistance Program.
Employee referral bonus.
Professional development assistance.
Some positions may qualify for the Public Service Loan Forgiveness Program.