Director of Compliance and Quality Improvement

About the Role: As the Director of Compliance and Quality Improvement at Katie Blessing Center, you will play a pivotal, high-impact role driving the operational launch, regulatory readiness, corporate ethics, and clinical quality standards of our new hospital. As a key member of the KBC team, this role will have significant responsibility during the pre-opening phase. You will develop and implement the hospital’s regulatory and accreditation readiness strategy, build core quality, compliance, risk, patient safety, and privacy programs, and ensure required processes are fully operational before the hospital opens its doors and undergoes licensure and accreditation surveys. In this hands-on, working director role, you won’t just audit processes – you will build the culture. You will establish and execute our Quality Assessment and Performance Improvement (QAPI) plan, Enterprise Risk framework, Patient Safety Program, and Corporate Compliance/Privacy safeguards (HIPAA / 42 CFR Part 2). You will champion a Just Culture of non-retaliatory reporting, drive continuous survey readiness, and ensure total alignment with CMS Conditions of Participation, The Joint Commission standards, and North Carolina regulatory requirements.

Key Responsibilities: Quality & Performance Improvement (QAPI): Develop, execute, and evaluate the hospital’s annual QAPI Plan. Establish meaningful clinical, operational, and patient-experience indicators, build executive dashboards, and lead multidisciplinary teams using structured PI methodologies (PDSA, Lean). Corporate Compliance & Privacy: Manage the hospital’s Corporate Compliance Program in accordance with OIG guidelines. Oversee the anonymous hotline, investigate ethics/FWA allegations, enforce HIPAA and 42 CFR Part 2 privacy standards, and manage monthly OIG/SAM exclusion screenings. Enterprise Risk & Patient Safety: Lead patient safety initiatives tailored to pediatric psychiatric care—including ligature-risk mitigation, suicide/self-harm prevention, elopement reduction, and restraint/seclusion reduction. Oversee incident triage, RCAs, FMEAs, and Sentinel Event reporting while maintaining the Enterprise Risk Register. Regulatory Compliance and Audit Oversight: Partner with Utilization Review (UR) and HIM to establish compliance audit schedules for medical necessity (mitigating Medicaid recoupment risks). Oversee institutional compliance with North Carolina Involuntary Commitment (IVC) legal hold statutes and mandatory Child Protective Services (CPS) reporting laws. Regulatory & Accreditation Readiness: Lead continuous survey readiness for CMS, The Joint Commission, and the NC Division of Health Service Regulation (DHSR)—directing mock tracers, gap assessments, and real-time survey operations. Governance & Leadership Reporting: Translate quality, safety, and compliance data into actionable reports for Executive Leadership, the Medical Executive Committee, and the Governing Board.

Education: Bachelor’s degree in Nursing, Healthcare Administration, Quality, Public Health, or a related healthcare field.

Experience: Minimum of five (5) years of healthcare experience, including at least three (3) years of hospital leadership experience in quality, compliance, risk management, regulatory readiness, or performance improvement.

Core Competencies: Demonstrated knowledge of QAPI frameworks, event investigation (RCA/FMEA), data interpretation, dashboard development, and regulatory readiness.

Preferred Qualifications: Advanced Degree: Master's degree in Healthcare Administration, Public Health, Nursing, Quality, Business, or a related field. Licensure: Registered Nurse (RN) with current North Carolina or compact-state licensure.

Specialized Experience: 3+ years in an inpatient psychiatric hospital, acute care, or pediatric behavioral health setting.

Accreditation Experience: Hands-on experience preparing for and managing Joint Commission and CMS hospital survey processes.

Certifications: Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Healthcare Risk Management (CPHRM), or Certified Professional in Patient Safety (CPPS).

Startup Experience: Direct experience with facility startups, opening a new hospital, or designing a QAPI/Compliance program from the ground up. Schedule and Work Location This position is full-time and on-site in Charlotte, North Carolina. It requires in-person presence, with flexibility as needed to support urgent regulatory surveys, investigations, and significant event reviews. Employment is subject to KBC’s applicable pre-employment requirements, including background screening and drug test.

Benefits: 401(k) with matching contribution Comprehensive Health, Dental and Vision Insurance Paid Time Off (PTO) Employee Assistance Program (EAP)