Quality & Compliance Manager

Job Description

POSITION SUMMARY:

The Quality Manager is responsible for leading and coordinating quality improvement initiatives, regulatory compliance, staff training, safety, and infection prevention efforts within a residential behavioral health program. This role ensures the delivery of safe, effective, and compliant care by overseeing incident reporting processes, leading investigations, managing policy review, facilitating staff education, and guiding the organization through regulatory standards established by Texas HHSC and Joint Commission Accreditation.

JOB-SPECIFIC RESPONSIBILITIES:

Quality Improvement & Risk Management

• Review, track, and analyze incident reports for trends and risk mitigation.

• Lead root cause analyses and quality investigations for incidents, grievances, and sentinel events.

• Chair the Quality Improvement Committee and lead quality assurance performance improvement (QAPI) activities.

• Develop and monitor corrective action plans and quality metrics in compliance with Joint Commission Accreditation and Health and Human Services Commission standards.

Regulatory Compliance

• Serve as the facility’s resource for Texas HHSC General Residential Operations Minimum Standards and Joint Commission Behavioral Health Accreditation standards.

• Prepare for and coordinate all external audits, surveys, and accreditation visits.

• Conduct internal compliance audits and monitor ongoing adherence to regulatory standards.

Training & Competency

• Organize and implement the annual clinical skills fair for direct care and clinical staff.

• Coordinate and deliver components of new employee orientation related to quality, safety, and regulatory compliance.

• Manage employee competency tracking and support departments in developing and evaluating staff competencies.

• Enhance professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.

Safety & Infection Prevention

• Oversee facility safety initiatives including environmental rounds and emergency preparedness drills.

• Monitor infection prevention practices and ensure compliance with CDC and facility protocols.

• Lead investigations and reports related to infection control breaches or outbreaks.

Skills & Competencies

• Strong analytical, investigative, and documentation skills.

• Excellent communication and training facilitation abilities.

• Ability to lead multidisciplinary committees and work collaboratively across departments.

• Proficient in Microsoft Office Suite and quality management software platforms.

• Maintains confidentiality of patient records.

• Complete all documentation as required or ensure the completion of all necessary documentation promptly and appropriately.

• Adheres to facility policies and procedures.

• Performs miscellaneous job-related duties as assigned.

POSITION QUALIFICATIONS:

EDUCATION:

• Bachelor’s degree in Nursing, Behavioral Health, Public Health, Healthcare Administration, or related field required; master’s degree preferred.

EXPERIENCE:

• Minimum of 3 years of experience in quality management or regulatory compliance in behavioral health or healthcare setting.

• Knowledge of Texas HHSC licensing standards and Joint Commission Behavioral Health standards required.

LICENSURE/CERTIFICATION:

• Certification in Quality (e.g., CPHQ) or Infection Prevention (e.g., CIC) preferred.

Full-time