Job Description

About the Role

We are seeking a highly skilled Director of Quality & Risk Management to lead our behavioral health facility’s quality, safety, regulatory compliance, and risk mitigation efforts. This leader will be responsible for ensuring coordinated, high-quality patient care in alignment with established clinical standards, mental health best practices, and organizational goals.

This is a key leadership role that partners closely with Nursing, Clinical Services, Case Management, and Executive Leadership to drive excellence in Performance Improvement (PI) , patient safety , regulatory readiness , and risk management activities across the facility.

Director of Quality and Risk Mgt

Key Responsibilities

Quality & Performance Improvement

• Lead the facility’s Quality and Performance Improvement (QAPI) initiatives, ensuring continuous improvement of patient care and safety.

• Monitor, evaluate, and report monthly PI and National Patient Safety Goals (NPSG) data to the CNO and CEO.

• Assess program effectiveness and implement improvement strategies.

• Support organization-wide quality goals and maintain confidentiality of sensitive information.
  

  Director of Quality and Risk Mgt

Risk Management & Patient Safety

• Ensure compliance with Joint Commission (TJC) , CMS , HCFA , and State regulations.

• Oversee safety and risk-management policies; investigate incidents and support corrective action plans.

• Process unusual occurrence reports and lead investigations, documentation, and follow-up.

• Coordinate legal processes and ensure accurate records regarding patient rights and safety.
  

  Director of Quality and Risk Mgt

Leadership & Collaboration

• Serve as a resource to clinical and nursing staff to ensure compliance with Standards of Care.

• Participate in Nurse Staffing and Nurse Managers meetings to promote safe, effective care delivery.

• Collaborate with Case Management to ensure timely and quality services for all patients.

• Participate in Administrator-on-Call rotation.

Regulatory Readiness & Compliance

• Maintain thorough knowledge of Joint Commission standards and support accreditation activities.

• Ensure adherence to facility policies, procedures, and professional standards.

Qualifications

• Education: Bachelor’s degree in Nursing required; Master’s in Psychiatric Nursing or related field preferred.

• Licensure: Valid RN license (State or Compact).

• Experience: Minimum 1 year in Nursing Administration or Nursing Leadership ; behavioral health experience strongly preferred.

• Skills:

  • Strong knowledge of psychiatric and medical nursing practices.

  • Proficiency in Microsoft Office.

  • Familiarity with Joint Commission standards.

  • Excellent organizational, communication, and leadership skills.

  • Ability to remain calm in emergencies and manage multiple priorities in a fast-paced environment.
    Director of Quality and Risk Mgt

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