Director of Quality Management Full Time

POSITION SUMMARY

The Director of Quality Management is a leadership position responsible for facilitating activities related to quality of care, licensing and accreditation, service delivery, and contracting within all Fora Health locations.

This role leads the Quality Management (QM) function to improve organizational efficiency and effectiveness, ensuring compliance with external and internal regulatory standards to achieve excellence in care. The Director monitors, identifies, reports, and documents the results of quality initiatives and collaborates with leaders to implement proactive, data-driven improvements.

As a visible and energetic champion of quality and patient care, the Director focuses on continual improvement in the safety, effectiveness, efficiency, patient-centeredness, equity, and timeliness of behavioral and medical health services. The Director also oversees all licensing and accreditation processes to secure continuous certification and endorsement from agencies such as CARF and NARR.

Essential Job Duties

• Provides direct administrative supervision and oversight to the Quality Specialist team.
• Utilizes clinical and operational data to identify quality issues, improvement opportunities, and monitor progress.
• Patient Satisfaction surveys
• Referent Satisfaction surveys
• Engagement/retention outcomes
• Incident Reports and Grievances
• Internal chart audits
• Develops and implements the annual Performance Measurement Plan in collaboration with the Sr. Director of Operations & Compliance and Executive Team.
• Develops and reviews performance indicators to assess the impact of programs.
• Collaborates in the creation of leadership dashboards and reports findings to the Executive Team, Quality Improvement Committee, and other key stakeholders.
• Oversees patient rights and grievance procedures.
• Oversees incident reports and participates in the Health & Safety Committee.
• Chairs the Quality Management Committee and ensures engagement from QM team members.
• Develops and maintains the Annual Quality Improvement Plan aligned with strategic goals, accreditation standards, and state regulations.
• Leads data collection, analysis, and reporting for quality and patient safety initiatives.
• Creates, modifies, and reviews policies and procedures with the Sr. Director of Operations & Compliance.
• Advocates for and implements Continuous Quality Improvement (CQI) principles across the organization.
• Collects and analyzes data on patient records, utilization management, and medication services.
• Evaluates the effectiveness of the Quality Management Program annually and as needed.
• Develops and presents the Annual Quality Improvement Report addressing high-risk, highvolume, or high-cost areas.
• Communicates Quality Management activities and findings to the CEO and Board of Directors as requested.
• Oversees all licensing and accreditation processes, ensuring continuous certification and compliance with corrective action plans.
• Serves as liaison for licensing, accreditation, and credentialing agencies.
• Prepares for and hosts site reviews, ensuring positive results with minimal findings.
• Ensures completion and communication of all corrective action plans within prescribed timeframes.
• Attends and represents Fora Health in community-based quality management meetings.
• Performs other related duties as required or assigned.

Additional Job Responsibilities

• Attend staff meetings as scheduled.
• Additional trainings to be completed as assigned in a timely manner.
• Special projects and other duties as assigned.
• Participate in ongoing supervision and consultation.
• Provide leadership to the teams in such a way that the work environment supports and encourages values of the agency: honesty, empathy, respect, inclusion, unity.
• Proactively identify barriers to effective medication administration systems and works with residential and medical staff to address them.
• Maintain quality treatment services that are responsive to client needs and reflect best practices.
• Oversees operational aspects of clinical tasks and roles and provides strategic advice/direction to functionalize the service delivery model.

Supervisory Functions

This position has supervisory duties.

Requirements

QUALIFICATIONS

Education And Experience Required

• Bachelor’s Degree in a health or human service field such as hospital administration, public health, allied health, or related area required.
• Master’s Degree preferred; may substitute for two (2) years of experience.
• Minimum of four (4) years of experience with multi-disciplinary work groups focused on service delivery and/or quality improvement in a healthcare setting.
• At least two (2) years of leadership experience managing teams or programs.
• Minimum of three (3) years supervisory or management experience required.
• Experience in healthcare quality management and data-driven decision-making.
• Proven ability to analyze and interpret aggregate data and produce actionable recommendations.
• Experience preparing reports and documentation for service delivery or quality assurance.

Knowledge, Skills And Abilities Required

• Strong knowledge of Continuous Quality Improvement (CQI) principles (e.g., Six Sigma, Lean).
• Strong analytical and problem-solving abilities; understanding of regulatory, licensure, and risk management standards.
• Experience with project management, clinical data collection, and process improvement.
• Knowledge of risk management, infection prevention, and patient safety.
• Excellent leadership, interpersonal, and communication skills.
• Ability to train, facilitate, and motivate cross-functional teams.
• Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and data analysis tools.
• Highly organized with strong attention to detail and ability to manage multiple projects.
• Positive attitude with creativity, initiative, and enthusiasm.
• Valid driver’s license, clean driving record (past 3 years), and current auto insurance.
• Ability to travel between Fora Health sites and attend external meetings as needed.
• Schedule may occasionally include evenings and weekends.

Other Requirements

• For employees with a history of substance use disorder, Fora Health’s policy requires certification of a minimum of six months of sobriety for this position.
• Ability to pass a pre-employment or for cause drug tests.
• Position will require some amount of regular connection to work via cell phone to answer questions and respond to internal and external contacts.

WORKING CONDITIONS

• Prolonged use of computer
• Position requires on-call availability to respond to emergency situations during off-duty hours including via cell phone.
• Position will require some amount of regular connection to work via cell phone to answer questions and respond to internal and external contacts.
• Position generally works in an indoor office environment with infrequent travel between sites or to special events.
• Primarily an indoor office environment with infrequent travel between sites or to special events.
• May occasionally require extended hours including evenings or weekends.
• Prolonged computer use.
• Fast-paced, high-volume work environment
• Position generally works in an indoor office environment with [frequent/occasional] travel between sites or to special events.
• Possible exposure to communicable diseases which can encompass a variety of illnesses and infections, including COVID, tuberculosis, Hepatitis A, B, and C, and HIV.
• Possible exposure to upset, angry, severely traumatized, disabled or emotionally disturbed adults, adolescents, and families.
• Exposure to potentially hazardous cleaning chemicals, personal protective equipment provided.
• Fast paced, high volume work environment.