Director of Quality and Compliance

Summary:

The Director of Quality and Compliance is a senior leader who designs, implements, and oversees an integrated enterprise quality and compliance program across the Consortium’s multi-program, multi-site operations. This role combines strategic quality improvement with operational compliance management, including regulatory readiness, licensure and credentialing oversight, mandatory compliance training tied to program licensing requirements, internal audit and investigation functions, and vendor and contract compliance. The Director ensures that evidence-based clinical practice, client safety, data privacy, and regulatory obligations are met while advancing continuous improvement and equity across services.

Core Responsibilities

Quality Assurance and Performance Improvement

· Design and maintain a comprehensive Quality Management System that standardizes quality practices across consortium partners while allowing program-level flexibility.
· Lead continuous quality improvement initiatives using data-driven methodologies including root cause analysis, PDSA cycles, Lean, and Six Sigma principles where appropriate.
· Develop and monitor KPIs for clinical outcomes, service access, client experience, safety events, and operational quality.
· Oversee incident reporting and critical event review, ensuring timely investigation, corrective action plans, and dissemination of lessons learned to prevent recurrence.
· Coordinate accreditation readiness and maintain standards for accrediting bodies and payer quality programs.

Regulatory Compliance and Risk Management

· Own enterprise compliance with federal, state, and local laws, program licensure requirements, Medicaid and Medicare rules, funder conditions, and contractual obligations.
· Maintain a regulatory calendar and lead preparation for licensing inspections, state audits, and site visits.
· Develop, update, and enforce policies that mitigate compliance risk including documentation standards, medication management, infection control, and mandated reporting.
· Serve as primary liaison with regulatory agencies, licensing boards, accrediting organizations, and funders during audits and investigations.
· Manage corrective action plans and ensure timely remediation of audit findings and regulatory citations.
· Oversee enterprise risk assessments and maintain a risk register with mitigation strategies and escalation pathways.

Compliance Training and Licensure Oversight

· Design and implement a comprehensive compliance training program that maps directly to licensure and certification requirements for each program and staff role.
· Maintain a centralized licensure and credentialing tracking system for staff, contractors, volunteers, and peer specialists; ensure timely renewals and documentation.
· Develop role-based curricula for mandatory trainings including HIPAA, 42 CFR Part 2, mandated reporting, cultural humility, trauma-informed care, harm reduction, infection control, and medication safety.
· Coordinate with HR and program leadership to ensure onboarding, competency assessments, continuing education, and remediation meet regulatory and funder standards.
· Monitor training completion and competency metrics and implement targeted remediation for non-compliance.
· Ensure training content is current with state licensing changes and program rules and that training delivery methods meet adult learning best practices.
Internal Audit, Monitoring, and Investigations
· Develop and execute an internal audit plan covering clinical documentation, billing and claims compliance, program eligibility, client rights, and safety protocols.
· Conduct mock surveys and readiness drills for licensing and accreditation reviews.
· Lead investigations into compliance breaches, allegations of abuse or neglect, fraud, or serious safety events; coordinate with legal counsel and external agencies as required.
· Implement corrective action and monitoring plans and report progress to executive leadership and the Board.

Data Governance, Reporting, and Analytics    

· Lead quality data strategy including data collection standards, validation, and reporting across EMR and program databases.
· Produce regular compliance and quality reports for executive leadership, the Board, funders, and regulatory bodies.
· Use analytics to inform practice — predictive indicators, trend analysis, and equity impact assessments drawn from the consortium’s longitudinal data.
· Ensure data integrity and security in collaboration with IT oversee privacy impact assessments when new systems are deployed.

Contract Compliance

· Oversee contract(s) compliance for contracted service providers, ensuring contractual deliverables, licensing, and insurance requirements are met.

Leadership, Collaboration, and Culture

· Serve as a senior advisor to executive leadership and the Board on quality, compliance, and risk matters.
· Build cross-organizational relationships across consortium partners to standardize practices while respecting local program needs.
· Supervise and mentor the Quality and Compliance team; foster a culture of continuous learning, transparency, and non-punitive improvement.
· Represent the Consortium in external coalitions, regulatory workgroups, and funder meetings related to quality and compliance.

Education

· Master’s degree in Public Health, Healthcare Administration, Social Work, or related field preferred. Bachelor’s degree with substantial relevant experience accepted.

Experience

· Minimum 3-5 years of progressive experience in quality assurance, compliance, or regulatory roles within behavioral health, substance use recovery, primary care or human services; minimum of 3 years in supervisory or leadership roles.

· Demonstrated experience managing multi-site or consortium programs and preparing for regulatory inspections and accreditation.

· Proven experience designing and delivering compliance training tied to licensure requirements.

· Experience conducting internal audits, investigations, and managing corrective action plans.

· Strong background with EMR systems, quality reporting, and data analytics.

· Familiarity with Medicaid/Medicare regulations, state licensing processes, and funder reporting requirements.

Preferred

· Prior experience at nonprofit social services, public health, primary care or behavioral health providers