Director of Quality Improvement & Privacy

Tennyson Center for Children•Denver, CO

4d•$115,000 - $120,000

About The Position

The Director of Quality Improvement and Privacy leads Tennyson Center for Children’s organization-wide quality improvement program, which encompasses compliance, risk management, outcome evaluation, accreditation, policy management, and privacy. The Director ensures adherence to 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 position is the organization’s designated Privacy Officer and PolicyTech system administrator, and supervises the Health Record Analyst. The Director partners with the Electronic Health Record Administrator and Chief Financial and Operations Officer on audit findings, privacy requirements, health information management, and client health data integrity. The role leads accreditation and licensing processes, administers risk management and privacy programs, oversees quality improvement initiatives and organizational reporting, and develops staff onboarding and training. It also manages PolicyTech policy review and document control, investigates privacy incidents, and communicates quality, compliance, and risk issues to executive leadership. The position may work remotely up to 40% of the time, with minimal travel, in a general office environment.

Requirements

Bachelor’s degree in behavioral health, social work, psychology, healthcare administration, human services, or a related field.
Minimum of 3 to 5 years of experience in quality improvement, quality assurance, compliance, or clinical operations; behavioral health or child-serving program experience is preferred.
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; experience with COA and CDHS is preferred.
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 successfully complete required pre-employment screening, 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 and complete employment eligibility verification upon hire; the employer does not sponsor work visas.
Must successfully complete a pre-hire physical.

Nice To Haves

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

Responsibilities

Develop and manage the compliance program, including related policies and reviews, to ensure compliance with state and federal regulations, licensing requirements, accreditation standards, and payer contracts.
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; respond to CDHS Reports of Investigations within required timeframes; maintain regulatory relationships; and recommend investigative procedures when violations are alleged.
Advise on accreditation and licensing status, gaps, and readiness, and partner with department directors on corrective plans.
Administer the risk management program in collaboration with the Chief Financial and Operations Officer, including adverse events, client rights and grievances, facility and staff safety, and media and reputational risks.
Oversee incident reporting, grievance tracking, investigations, and reviews of critical incidents and reportable events for timeliness, compliance, and appropriate trauma-informed interventions.
Identify risk trends and root causes, recommend preventive actions, and escalate significant safety, privacy, or compliance concerns to the Chief Program Officer and CEO.
Develop and deliver onboarding and annual training on risk management, compliance, audits, privacy and HIPAA, quality standards, documentation procedures, and client rights, in partnership with Human Resources; assess staff compliance knowledge.
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, implement, and oversee an organization-wide quality and performance improvement program using a closed-loop CQI/PQI approach.
Lead quality improvement initiatives focused on client safety, treatment effectiveness, family engagement, and youth outcomes, including restraints, elopements, abuse and neglect allegation reporting, client 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 incorporate new programs into 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 designated Privacy Officer, overseeing privacy issues involving health records, security, breach notifications, HIPAA, HITECH, FERPA, and IDEA.
Maintain privacy policies, procedures, and notices, and oversee privacy-related technology and security safeguards in collaboration with Information Technology and the Electronic Health Record Administrator.
Investigate suspected privacy violations and breaches of unsecured PHI and ensure required notifications, including to the HHS Office for Civil Rights, 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.