Vice President of Quality Assurance and Compliance

Lifeline Connections

Salary Range: $100,000 to $120,000 annually, dependent on experience

Position SummaryLifeline Connections is seeking a strategic and experienced Vice President of Quality Assurance and Compliance to serve as a senior executive leader responsible for advancing organizational excellence, regulatory compliance, accreditation readiness, patient safety, risk management, productivity oversight, data management, and continuous quality improvement across behavioral health programs and operations. This position partners closely with the CEO and Executive Leadership Team to develop and implement organization-wide strategies that promote clinical quality, operational integrity, regulatory compliance, data-informed decision-making, and measurable outcomes. The Vice President provides leadership for CARF and CCBHC accreditation readiness, quality assurance, compliance, incident management, performance improvement, documentation standards, productivity monitoring, workforce competency development, and evidence-based practice fidelity.The successful candidate will promote a culture of ethical practice, transparency, accountability, trauma-informed care, continuous learning, operational excellence, and person-centered service delivery.

Essential Duties and Responsibilities

Executive Leadership and StrategyServes as a strategic advisor to the CEO and Executive Leadership Team regarding quality improvement, compliance, accreditation, patient safety, productivity, data integrity, and organizational risk management.Collaborates with executive leadership on strategic planning, operational planning, workforce development, value-based payment readiness, utilization management, quality outcomes, and organizational performance improvement.Provides leadership in developing a culture focused on compliance, ethical decision-making, service excellence, data-informed leadership, continuous improvement, and operational accountability.

Regulatory Compliance and AccreditationEnsures organizational compliance with applicable federal, state, and local behavioral health regulations, including WAC, RCW, ORS, OAR, DOH, DSHS, CMS, OSHA, HIPAA, 42 CFR Part 2, CARF, CCBHC, Medicaid, and other applicable regulatory or accreditation standards.Maintains organizational readiness for CARF surveys, CCBHC requirements, DOH licensing reviews, Medicaid audits, payer audits, and other regulatory or accreditation inspections.Oversees corrective action planning related to audit findings, incidents, grievances, compliance deficiencies, accreditation recommendations, documentation gaps, productivity concerns, and performance improvement opportunities.Serves as the organization’s Compliance and Privacy Officer and oversees compliance and privacy reporting processes.

Quality Assurance, Productivity, and Performance ImprovementDevelops, implements, and oversees organization-wide quality assurance and performance improvement systems.Establishes measurable quality indicators, key performance indicators, productivity benchmarks, documentation standards, treatment outcome measures, access metrics, utilization trends, and program performance expectations.Oversees the collection, analysis, interpretation, validation, and reporting of quality, compliance, productivity, and operational performance data.Ensures data is accurate, timely, actionable, and used to guide decision-making at the program, department, executive, and Board levels.Leads continuous quality improvement initiatives focused on patient outcomes, patient safety, access to care, service effectiveness, compliance, documentation quality, productivity, data integrity, operational efficiency, and overall organizational performance.Ensures fidelity to evidence-based and promising practices through monitoring, auditing, coaching, staff development, data review, and corrective action processes.Staffs the Quality Assurance and Performance Improvement Committee and provides regular quality, compliance, productivity, and performance reports to executive leadership and the Board of Directors.

Data Management and ReportingProvides broad oversight of organizational data management practices related to quality, compliance, productivity, outcomes, incident reporting, accreditation readiness, documentation, and operational performance.Partners with clinical, operational, finance, compliance, records, and electronic health record teams to strengthen data accuracy, reporting workflows, dashboard development, performance monitoring, and data-informed decision-making.Supports the development and implementation of reporting tools, dashboards, scorecards, audits, and other systems used to track productivity, service delivery trends, regulatory compliance, documentation quality, and organizational outcomes.

Risk Management and Patient SafetyOversees risk management activities, including incident reporting, sentinel event review, root cause analysis, corrective action implementation, patient grievances, patient feedback, compliance investigations, and patient safety initiatives.Identifies clinical, operational, financial, productivity, data integrity, and compliance-related risks and develops mitigation strategies in partnership with executive and program leadership.Ensures appropriate response protocols are implemented for regulatory incidents, patient complaints, adverse events, compliance concerns, documentation deficiencies, and performance-related risks.

Policy Development and Operational OversightDevelops, reviews, updates, and implements organizational policies, procedures, workflows, and compliance protocols consistent with regulatory, payer, accreditation, privacy, and operational standards.Provides oversight of assigned departments and functions, which may include quality assurance, compliance, records management, electronic health records, data reporting, productivity monitoring, and performance improvement.Supports the development and implementation of new programs, workflows, documentation practices, data systems, productivity expectations, and operational processes related to quality assurance and compliance.Ensures documentation systems, recordkeeping practices, reporting workflows, and data management processes meet organizational, regulatory, payer, and accreditation standards.

Workforce Development and Competency ManagementDevelops and oversees competency-based staff development systems consistent with CARF, CCBHC, regulatory, and organizational standards.Leads staff education and training initiatives related to compliance, HIPAA, patient safety, documentation standards, incident reporting, quality improvement, productivity expectations, data integrity, evidence-based practices, ethical conduct, and accreditation readiness.Supervises assigned staff and leaders, including performance management, coaching, corrective action, professional development, and accountability for departmental goals.Supports leadership development, succession planning, workforce competency assessment, and staff understanding of quality, compliance, productivity, and data management expectations.

Community and Organizational RepresentationRepresents Lifeline Connections with regulatory agencies, accrediting bodies, community partners, external auditors, payers, and stakeholders.Serves as staff support to assigned Board Committees and provides formal reports and presentations as requested by the CEO.Participates in after-hours consultation and executive response activities as needed. Performs other duties as assigned.

Core CompetenciesStrategic leadership; regulatory compliance; CARF and CCBHC accreditation readiness; risk management; continuous quality improvement; productivity management; data analytics; outcome measurement; executive communication; ethical decision-making; trauma-informed leadership; change management; policy development; workforce development; operational excellence; interdisciplinary collaboration; problem solving; critical thinking; cultural humility; and inclusive leadership.

Minimum QualificationsMaster’s degree in Behavioral Health, Healthcare Administration, Social Work, Counseling, Public Health, Nursing, Psychology, or related field required.Minimum of five years of progressive leadership experience in behavioral health quality assurance, compliance, risk management, accreditation, healthcare operations, or related areas required.Minimum of three years of supervisory or executive leadership experience in a behavioral health or healthcare setting required.Demonstrated experience with CARF accreditation, CCBHC demonstration or certification, regulatory audits, quality improvement systems, incident management, compliance investigations, policy development, productivity monitoring, data analysis, organizational reporting, and performance improvement initiatives.Knowledge of WAC 246-341, RCW 71.24, HIPAA, 42 CFR Part 2, CMS requirements, CARF standards, CCBHC requirements, behavioral health licensing standards, and Medicaid documentation requirements.Ability to analyze organizational data, develop performance metrics and key performance indicators, evaluate productivity trends, identify performance gaps, and lead corrective action initiatives.Strong written, verbal, presentation, analytical, and executive communication skills required.Preferred QualificationsLicensed Mental Health Professional, such as LMHC, LICSW, LMFT, PsyD, PhD, RN, or related credential preferred.Mental Health Professional designation consistent with WAC 246-341 preferred.Certified Professional in Healthcare Risk Management, Certified Professional in Patient Safety, Certified in Healthcare Compliance, Lean/Six Sigma training or certification, or related credential preferred.Experience serving in a Compliance Officer or Privacy Officer role preferred.Experience leading CARF surveys, accreditation readiness activities, CCBHC implementation, accreditation, or readiness activities preferred.

Lifeline Connections

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Vice President of Quality Assurance and Compliance