Tennyson Center for Children

Therapeutic school and trauma-focused services

Director of Quality Improvement and Privacy

Regulatory Compliance & Ethics +1Confirmed live in the last 24 hours

Full-timeDenver, CO, USA$115k - $120k /yr

About the Job

Requirements

A bachelor's degree in behavioral health, social work, psychology, healthcare administration, human services, or a related field is required.
At least 3 to 5 years of experience in quality improvement, quality assurance, compliance, or clinical operations is required; experience in behavioral health or child-serving programs is preferred.
Demonstrated knowledge of HIPAA privacy, security, and breach notification requirements, behavioral health regulations, clinical documentation standards, and quality improvement methodologies.
Experience with audits, performance data, corrective action plans, and regulatory or accreditation reviews.
Strong analytical, organizational, communication, leadership, and problem-solving skills.
Ability to collaborate effectively with multidisciplinary teams, support staff development, and manage confidential information with discretion.
Must have or qualify to obtain a current Colorado driver's license.
Must successfully complete a pre-hire physical and the required pre-employment drug test, FBI fingerprint check, CBI criminal records check, child abuse registry check, motor vehicle record check, academic record verification, and reference checks.
Must demonstrate eligibility to work in the United States.

Responsibilities

Develop and manage the compliance program, including related policies and compliance reviews, to ensure compliance with state and federal regulations, licensing requirements, accreditation standards, and payer contracts, especially CDHS Child Welfare Volume 7 and Community Services Volume 8, CDE requirements, and FERPA/IDEA.
Lead the Council on Accreditation accreditation process and annual CDHS licensing process, and ensure ongoing readiness for all programs.
Lead CDHS TRAILS reporting and background checks, respond to CDHS Reports of Investigations within required timeframes, maintain relationships with regulatory bodies, and recommend investigative procedures when violations are alleged.
Serve as the accreditation and licensing subject matter expert, communicate survey status, gaps, and readiness to the Chief Program Officer and CEO, and partner with department directors to implement corrective plans.
Administer the risk management program in collaboration with the Chief Financial and Operations Officer, covering adverse events, client rights and grievances, facility and staff safety, and media and reputational risks.
Oversee incident reporting, grievance tracking, and investigations; review critical incidents and reportable events for timeliness, regulatory compliance, and appropriate trauma-informed interventions.
Identify trends and root causes, recommend preventive actions, and escalate significant safety, privacy, or compliance concerns to the Chief Program Officer and CEO.
Develop and deliver onboarding and annual training for all staff in risk management, compliance, audits, privacy and HIPAA, quality standards, documentation procedures, and client rights; assess staff's ongoing compliance knowledge in partnership with Human Resources.
Gather, validate, and report data from quality improvement and risk management processes, including key performance indicators, monthly, quarterly, and annually.
Lead development of organizational dashboards, monitor clinical outcomes and strategic plan progress, and communicate results to the Chief Program Officer, senior leadership, and CEO.
Prepare quality reports and presentations of impact for leadership, committees, the Board of Directors, and marketing and development.
Develop, implement, and oversee the organization's quality and performance improvement program using a closed-loop Continuous Quality Improvement approach across all programs.
Lead quality improvement initiatives focused on client safety, treatment effectiveness, family engagement, and youth outcomes, including restraint use, elopements, timely reporting of abuse and neglect allegations, client record audits, and staff retention.
Develop and monitor performance indicators, corrective action plans, and improvement goals, and conduct internal audits and chart reviews as appropriate.
Review quarterly SmartCare audits conducted by the Electronic Health Record Administrator and recommend corrective actions.
Collaborate with clinical and executive leadership to add new programs into the Continuous Quality Improvement process, hold staff accountable for accurate data collection, and support continuous improvement.
Serve as the system administrator for PolicyTech, including periodic policy review, approval, and version control.
Work with policy owners to revise policies based on regulatory changes, audit findings, and incident trends, and oversee forms management and document control.
Serve as the designated Privacy Officer, overseeing privacy issues, including HIPAA and individual health records privacy, security, and breach notification requirements, the HITECH Act, and FERPA/IDEA.
Maintain privacy policies, procedures, and notices, and oversee technology and security safeguards that affect privacy in collaboration with Information Technology and the Electronic Health Record Administrator.
Investigate suspected privacy violations and breaches of unsecured protected health information, and ensure required notifications, including to the HHS Office for Civil Rights, are completed on time.
Coordinate privacy complaints and risk assessments, and document investigations and corrective actions.
Supervise, coach, and evaluate the Health Record Analyst, and partner with the Electronic Health Record Administrator and Chief Financial and Operations Officer on health information management and data integrity.
Perform other duties as assigned.

Desired Qualifications

A master's degree is preferred.
Experience in behavioral health or child-serving programs is preferred.
Experience serving children, adolescents, and families in behavioral health settings is preferred.
Supervisory experience is preferred.
A professional certification such as CHC, CPHQ, or CHPC is preferred.

Job Summary and Purpose

At Tennyson Center for Children, our core values guide everything we do. We are Joyful, finding optimism and strength even in challenges; Curious, always learning and innovating to provide the best care; Dependable, building trust through reliability; Authentic, celebrating uniqueness and creating safe, inclusive spaces; and Compassionate, deeply caring for our teammates, our clients, and the community we serve. If these values resonate with you, we’d love to have you join our team and help us make a lasting impact on the lives of children across Colorado!

The Director of Quality Improvement and Privacy leads the organization’s quality improvement program, which serves as the umbrella over compliance, risk management, outcome evaluation, accreditation, policy management, and privacy. The Director ensures compliance with applicable state and federal regulations, licensing requirements, accreditation standards, and payer contracts, and promotes a culture of safety, continuous learning, trauma informed care, and family centered services throughout Tennyson. The Director serves as Tennyson Center’s designated Privacy Officer, serves as the PolicyTech system administrator, and supervises the Health Record Analyst. Health information management and client health data integrity are led within Finance and Operations, and the Director partners with the Electronic Health Record Administrator and the Chief Financial and Operations Officer so that audit findings and privacy requirements are addressed.

Essential Job Functions

Compliance, Accreditation and Licensing (COA and CDHS)

Develop and manage Tennyson Center’s compliance program, including related policies and compliance reviews, to ensure compliance with state and federal regulations, licensing requirements, accreditation standards, and payer contracts, especially CDHS Child Welfare Volume 7 and Community Services Volume 8, CDE requirements, and FERPA/IDEA
Lead Tennyson Center’s Council on Accreditation (COA) accreditation process and the annual CDHS licensing process, and ensure ongoing readiness for all programs
Lead CDHS TRAILS reporting and background checks, the response to CDHS Reports of Investigations (ROIs) within required timeframes, maintain relationships with regulatory bodies, and recommend investigative procedures when violations are alleged
Serve as the subject matter expert in accreditation and licensing, communicating survey status, gaps, and readiness to the Chief Program Officer and CEO and partnering with department directors to implement corrective plans

Risk Management

Administer the risk management program in collaboration with the Chief Financial and Operations Officer, covering adverse events, client rights and grievances, facility and staff safety, and media and reputational risks
Oversee incident reporting, grievance tracking, and investigations, and review critical incidents and reportable events, for timeliness, regulatory compliance, and appropriate, trauma-informed interventions
Identify trends and root causes, recommend preventive actions, and escalate significant safety, privacy, or compliance concerns to the Chief Program Officer and CEO

Onboarding and Training

Develop and deliver onboarding and annual training for all staff in risk management, compliance, audits, privacy and HIPAA, quality standards, documentation procedures, and client rights, and assess staff’s ongoing compliance knowledge, in partnership with Human Resources

Impact and Outcome Evaluation and Reporting

Gather, validate, and report data from quality improvement and risk management processes, including key performance indicators (KPIs), monthly, quarterly, and annually
Lead development of the organizational dashboards, monitor clinical outcomes and strategic plan progress, and communicate results to the Chief Program Officer, senior leadership, and CEO
Prepare quality reports and presentations of impact for leadership, committees, the Board of Directors, and marketing and development

Quality Improvement

Develop, implement, and oversee the organization’s quality and performance improvement program, using a closed loop Continuous Quality Improvement (CQI/PQI) approach across all programs
Lead quality improvement initiatives focused on client safety, treatment effectiveness, family engagement, and outcomes for youth, including restraints use, elopements, timely reporting of abuse and neglect allegations, client record audits, and staff retention
Develop and monitor performance indicators, corrective action plans, and improvement goals, and conduct internal audits and chart reviews as appropriate
Review the quarterly SmartCare audits conducted by the Electronic Health Record Administrator and recommend corrective actions
Collaborate with clinical and executive leadership to add new programs into the CQI process, hold staff accountable for accurate data collection, and support continuous improvement

PolicyTech System Administrator

Serve as the system administrator for PolicyTech, Tennyson Center’s electronic policy management system, including periodic policy review, approval, and version control
Work with policy owners to revise policies based on regulatory changes, audit findings, and incident trends, and oversee forms management and document control

Privacy Officer

Serve as Tennyson Center’s designated Privacy Officer, with oversight of all privacy issues, including HIPAA/individual health records privacy, security, and breach notification requirements, the HITECH Act, FERPA/IDEA.
Maintain privacy policies, procedures, and notices, and oversee technology and security safeguards that affect privacy in collaboration with Information Technology and the Electronic Health Record Administrator
Investigate suspected privacy violations and breaches of unsecured PHI, and ensure required notifications, including to the HHS Office for Civil Rights, are completed on time
Coordinate privacy complaints and risk assessments, and document investigations and corrective actions

Leadership and Supervision

Supervise, coach, and evaluate the Health Record Analyst, and partner with the Electronic Health Record Administrator and the Chief Financial and Operations Officer on health information management and data integrity
Perform other duties as assigned

Physical Requirements

Must be able to successfully complete a pre-hire physical
Minimal physical requirements, occasional lifting up to 10 pounds
Must be able to sit for prolonged periods of time in an office setting
Ability to use office equipment

Working Conditions

General office environment
Minimal travel requirement
May work remote up to 40% of the time

Minimum Qualifications

Bachelor’s degree in behavioral health, social work, psychology, healthcare administration, human services, or a related field required; master’s degree preferred
Minimum of 3 to 5 years of experience in quality improvement, quality assurance, compliance, or clinical operations, preferably in behavioral health or child serving programs
Demonstrated knowledge of HIPAA privacy, security, and breach notification requirements, behavioral health regulations, clinical documentation standards, and quality improvement methodologies
Experience with audits, performance data, corrective action plans, and regulatory or accreditation reviews, preferably with COA and CDHS
Strong analytical, organizational, communication, leadership, and problem-solving skills
Ability to collaborate effectively with multidisciplinary teams, support staff development, and manage confidential information with discretion
Preferred: Experience serving children, adolescents, and families in behavioral health settings
Preferred: Supervisory experience, and a professional certification such as CHC, CPHQ, or CHPC
All candidates must have (or qualify to obtain) a current Colorado driver's license
All positions require a pre-employment drug test, FBI fingerprint check, CBI criminal records check, child abuse registry check, motor vehicle record check, academic record verification, and reference checks

Benefits

For employees working 30 or more hours per week:

Medical, Dental, & Vision Insurance options
Generous Paid Time Off
13 paid holidays
Paid Mental Health days to regroup & recharge
Retirement Plan with a match up to 4% of your annual salary
Pet, Legal & Identity Theft insurance options
HSA & FSA options
Accident, Critical Illness, Disability & Hospital Indemnity insurance options
Company paid Life Insurance & AD&D with options to purchase additional coverage
Employee Assistance Program
Employee Referral Bonus
Professional Development Assistance
Some positions may qualify for the Public Service Loan Forgiveness Program. For more information, go to https://www.colorado.gov/pacific/dhr/student-loan-forgiveness-programs

The estimated salary for this role is $115,000.00 - $120,000.00 annually.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

EEOC

Must demonstrate eligibility to work in the United States in compliance with federal law. All persons hired will be required to verify their eligibility to work in the United States and to complete the required employment eligibility verification form upon hire. Tennyson Center for Children currently does not sponsor work visas.

Tennyson Center is an equal opportunity and affirmative action employer; we are committed to creating an inclusive environment for all employees. We seek applicants of diverse backgrounds and prohibit discrimination based on race, religion, color, sex, sexual orientation, gender identity, gender expression, age, national origin, disability, military status, conditions relating to pregnancy or childbearing, and/or any other status protected by federal, state, or local laws. If you have any questions, please email our team at [email protected]. We appreciate your interest in Tennyson Center for Children.

About the Company

Tennyson Center for Children

Therapeutic school and trauma-focused services

Tennyson Center for Children provides mental health and wellness services for children and families affected by trauma. It runs an on-site accredited therapeutic K-12 school with a 3:1 student-to-staff ratio, plus in-home and community therapy across 12 counties, and residential services for youth through the Children’s Habilitation Residential Program. It combines education, therapy, and residential care in one organization to coordinate care, with a long history dating back to 1904 and a statewide Rewiring initiative to keep families together. Its goal is to improve mental health and well-being for traumatized children and their families and reduce involvement with the child welfare system.

Company size: 51-200
Company stage: Not listed
Total funding: Not listed
Headquarters: Denver, CO
Founded: 1904

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