Minnesota Mental Health Clinics is seeking an experienced and driven Director of Compliance and Quality to lead our organization’s compliance efforts and ensure that all clinical and operational services meet regulatory, ethical, and professional standards. This role involves overseeing the development, implementation, and maintenance of compliance programs while fostering a culture of continuous improvement in service quality.
Role responsibilities and duties include:
Regulatory Compliance:
- Ensure the organization complies with all state, federal, and local laws, including HIPAA, OSHA, CMS, and Minnesota mental health statutes.
- Serve as the primary liaison with regulatory bodies, preparing for audits, maintaining licensure, and reporting as necessary.
- Develop, review, and update organizational policies to reflect changes in regulations and ensure clinic-wide compliance.
- Create a designated repository with version control for policies, external communications, and internal bulletins to ensure consistency, easy access, and standardization.
Quality Assurance and Improvement:
- Lead the creation and implementation of a comprehensive quality management plan focused on clinical outcomes, client satisfaction, and continuous service improvement.
- Establish a system for quality audits, including chart reviews, performance assessments, and client safety initiatives.
- Collaborate with clinical leadership to identify areas for improvement and develop targeted interventions to enhance service quality.
- Work closely with training and clinical education staff to ensure supervision practices and trainings are aligned with all governing rules and ethical standards.
Training and Education:
- Create user-friendly learning documents, resources, and toolkits that empower all staff to understand and demonstrate adherence to clinical policies, ethical standards, and regulatory guidelines.
- Partner with the clinical education team to develop and deliver continuous professional development programs that align with current regulations and promote best practices.
- Ensure all training materials reflect the latest requirements from state and federal laws, ethics codes, and any other governing bodies relevant to clinical practice.
- Collaborate with leadership to develop clear communication pathways for sharing updates on policies and quality standards with all staff.
Risk Management:
- Identify, assess, and address risks within the organization’s operations and clinical services.
- Partner with organizational leadership to develop the organization’s risk management activities, including incident reporting, investigation, and mitigation strategies.
- Collaborate with leadership to develop a proactive approach to reducing potential legal and operational risks.
Accreditation Management:
- Assist, in collaboration with line of business clinical and operational leaders, in the maintenance of all necessary accreditations and certifications by coordinating self-assessments, preparing documentation, and managing relationships with accrediting bodies.
- Work closely with other department leaders, including clinical supervisors, billing, and IT, to integrate compliance and quality initiatives across all areas.
Requirements:
- Bachelor’s or Master’s degree in Healthcare Administration, Social Work, Psychology, or a related field.
- 2+ years of experience in healthcare compliance, quality assurance, or a related role, with a focus on mental health services.
- Deep understanding of state and federal regulations, especially pertaining to behavioral health.
- Strong leadership, communication, and interpersonal skills.
- Ability to analyze data and present findings to various stakeholders.
2025 Goals
Project Based Goal: Review all current organizational policies to ensure they are compliant with state, federal, and industry standards. Update any outdated policies, and by the end of the year, establish a systematic process for ongoing policy review and updates to ensure continued compliance and alignment with best practices.
Project Based Goal: Collaborate with clinical education leaders to develop and launch a course focused on enhancing clinical skills and performance among the clinical team. The course will be designed to support ongoing professional development and improve clinical outcomes.
Metric Based Goal: Establish a comprehensive quality measurement system for each service offering by the end of the year. Gather baseline data for all services, and set quarterly improvement goals through 2026 to drive continuous quality enhancement and ensure the highest standard of care across the organization.