Performance Improv.)

Northern California Behavioral Health System•Sacramento, CA

1d•$140 - $170

About The Position

At Sacramento Behavioral Healthcare Hospital, we're on a mission to deliver compassionate, high-quality behavioral health care and we need a sharp, driven leader to help us make sure we're doing it right, every single day. That's where you come in. As our Director of Quality Improvement, Risk Management & Performance Improvement, you'll sit at the intersection of data, compliance, and real human impact — turning insights into action and helping us build something we're all proud of.

Requirements

Bachelor’s degree in Nursing, Healthcare Administration, Public Health, Behavioral Health, or related field.
Minimum of two (2) years of experience in quality improvement, risk management, or regulatory compliance in a healthcare setting.
Experience in behavioral health or psychiatric inpatient services.
Strong knowledge of CMS, TJC Behavioral Health Care standards, DHCS, and California hospital standards and regulations.
Demonstrated experience leading PI projects and conducting RCA/FMEA.
Excellent analytical, communication, and leadership skills.
Current knowledge of continuous quality improvement methodology.
Current CPR certification or obtained during initial orientation period.
Current HWC (Handle with Care) or obtained during initial orientation period.

Nice To Haves

Master’s degree in a related field.
Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or equivalent.
Experience with trauma-informed care frameworks and high-reliability principles.
Prior leadership experience in a hospital or behavioral health organization.

Responsibilities

Lead the design, implementation, and evaluation of the hospital’s integrated Quality and Performance Improvement Program, ensuring alignment with CMS Conditions of Participation, The Joint Commission (TJC) Behavioral Health Care standards, and DHCS requirements.
Facilitate interdisciplinary QI/PI committees, workgroups, and data‑driven initiatives to improve clinical outcomes, patient experience, and operational efficiency.
Oversee data collection, analysis, and reporting for key quality metrics, including adverse events, readmissions, seclusion/restraint use, and patient satisfaction.
Partner with clinical and operational leaders to develop corrective action plans and monitor sustained improvement.
Promote a culture of continuous learning, transparency, and accountability across the organization.
Direct the hospital’s Risk Management Program, including incident reporting, investigations, root cause analyses (RCA), and proactive risk assessments (FMEA).
Serve as the primary point of contact for patient safety events, grievances, and regulatory reporting (CDPH, DHCS, CMS).
Maintain the hospital’s risk register and lead strategies to reduce clinical, operational, and environmental risks.
Collaborate with legal counsel and insurance carriers on claims management and risk mitigation strategies.
Provide training and coaching to staff on risk prevention, documentation standards, and safety practices.
Ensure continuous readiness for all accreditation and licensing surveys, including TJC, CMS, DHCS, and county mental health plans.
Conduct mock surveys, tracers, and compliance audits to identify gaps and drive corrective actions.
Maintain current knowledge of federal and California behavioral health regulations, ensuring timely updates to policies and procedures.
Coordinate submission of required regulatory reports and documentation.
Serve as the hospital’s Accreditation Manager and primary liaison with external regulatory bodies.
Lead and mentor a multidisciplinary team responsible for QI, RM, PI, and compliance functions.
Collaborate with nursing, medical staff, clinical services, and administrative departments to integrate quality and safety into daily operations.
Present performance dashboards, risk trends, and compliance updates to executive leadership and the Board of Directors.
Champion a patient‑centered, trauma‑informed, recovery‑oriented approach across all initiatives.