Core Competencies

• Joint Commission Accreditation Readiness
• Behavioral Health Compliance
• Efficiency and Effectiveness
• Scheduling 
• Technology
• Systems Administration
• Continuous Survey Readiness
• Quality Improvement (QAPI)
• Environment of Care
• Life Safety
• Infection Prevention
• Risk Management
• Regulatory Auditing
• Policy Development
• Performance Improvement
• Project Management
• Leadership Development
• Data Analytics
• Change Management
• Interdisciplinary Collaboration

Performance Expectations

Success in this role is demonstrated by:

• Continuous Joint Commission survey readiness with no significant findings.
• Successful state licensing and accreditation surveys.
• Managing technical floor staff.
• Completion of annual policy reviews.
• Improved quality and patient safety metrics.
• Safety Officer.
• Timely completion of staff compliance education.
• Effective oversight of QAPI initiatives.
• High compliance with Environment of Care and Life Safety standards.
• Positive collaboration with clinical leaders.
• Daily, weekly monthly KPI reporting

Work Environment

This position works within a Joint Commission-accredited residential behavioral health treatment facility. The role requires regular interaction with patients, clinical staff, medical providers, executive leadership, regulatory agencies, contractors, and external surveyors. Evening and weekend availability are required.

• Environment of Care (EC) Committee
• Life Safety (LS) Program
• Emergency Management (EM) Program
• Infection Prevention and Control (IC)
• Performance Improvement (PI/QAPI)
• Risk Management
• Incident Review and Sentinel Event follow-up
• Policy and Procedure Management
• Document Control
• Staff Competency Tracking
• Clinical and Operational Audits
• Corrective Action Plan (CAP) oversight
• Joint Commission survey readiness and mock surveys
• State licensing inspections
• Governing Body reporting

Required

• Bachelor's degree in Healthcare Administration, Nursing, Public Health, Business Administration, Behavioral Health, or related field.
• Minimum five years of progressive leadership experience in behavioral healthcare.
• Minimum three years of compliance, accreditation, quality improvement, or operations management experience.
• Demonstrated experience preparing organizations for Joint Commission surveys.
• Working knowledge of Joint Commission BHHS Accreditation Standards.
• Knowledge of behavioral health licensing regulations.
• Strong analytical, organizational, and project management skills.
• Excellent written and verbal communication skills.

Preferred

• Master's degree in Healthcare Administration, Nursing, Public Health, Business Administration, or related field.
• Certified Professional in Healthcare Quality (CPHQ).
• Certified in Healthcare Compliance (CHC).
• Certified Professional in Patient Safety (CPPS).
• Lean Six Sigma Green Belt or higher.
• Experience in residential mental health and/or substance use treatment.
• Experience with electronic health record systems and compliance auditing software.