Director of Quality

Alpine Vista; Colorado Springs (CO); On-site; USD 120,000 - 180,000; Full time

Benefits offered by this job

Medical plans

PTO and paid holidays

401(k) with employer contribution

Life and disability coverage

Tuition reimbursement

Student loan forgiveness programs

Mission-driven hospital environment

Job summary

Alpine Vista in Colorado Springs operates a behavioral health hospital seeking a Director of Quality to provide strategic leadership in quality improvement, patient safety, and risk management. You will drive QAPI, oversee risk and incident reporting, and ensure regulatory compliance to Joint Commission and CMS standards.

The role partners with nursing, medical staff, and clinical leadership to elevate outcomes, while fostering a culture of continuous improvement and accountability in care

Qualifications

• 5+ years of healthcare quality leadership experience, preferably in behavioral health.
• Strong knowledge of Joint Commission standards and CMS Conditions of Participation.
• Experience with data analysis, regulatory readiness, and survey management.
• Ability to influence multidisciplinary teams and drive sustainable improvement.

Responsibilities

• Lead the hospital’s QAPI program and oversee risk management, patient safety, and incident reporting.
• Ensure compliance with Joint Commission, CMS, state and federal regulations.
• Prepare the organization for accreditation surveys, audits, and regulatory reviews.
• Analyze clinical and safety data to identify trends and improvement opportunities.
• Facilitate root cause analyses and performance improvement plans.
• Partner with Nursing, Medical Staff, and Clinical Leadership to improve outcomes.
• Oversee policy management, regulatory updates, and quality-related education.
• Monitor behavioral health metrics and present data to leadership and governance.

Skills

Healthcare quality leadership

Regulatory readiness

Data analysis

Influence multidisciplinary teams

Job description

Schedule: Day Shift

Leadership: On-Call, as Needed

Lead Quality, Safety, and Excellence in Behavioral Health Care

The Director of Quality provides strategic and operational leadership for quality improvement, patient safety, and risk management across our psychiatric hospital. This role ensures that care delivery meets or exceeds regulatory, accreditation, and clinical best-practice standards, while fostering a culture of continuous improvement, accountability, and patient-centered care in a behavioral health environment.

What You’ll Do

• Lead the hospital’s Quality Assessment and Performance Improvement (QAPI) program
• Oversee risk management, patient safety, grievance management, and incident reporting
• Ensure ongoing compliance with Joint Commission, CMS, state, and federal regulations
• Prepare the organization for accreditation surveys, audits, and regulatory reviews
• Analyze clinical, operational, and safety data to identify trends and improvement opportunities
• Facilitate root cause analyses (RCA) and performance improvement plans
• Partner with Nursing, Medical Staff, and Clinical Leadership to improve outcomes
• Oversee policy management, regulatory updates, and quality-related education
• Monitor behavioral health–specific metrics including restraint/seclusion use, safety events, and patient experience
• Present quality and safety data to executive leadership and governing bodies

What We’re Looking For

• 5+ years of healthcare quality leadership experience, preferably in a psychiatric or behavioral health hospital
• Strong working knowledge of:
  • Joint Commission behavioral health standards
  • CMS Conditions of Participation
  • QAPI and patient safety frameworks
  • Experience with data analysis, regulatory readiness, and survey management
  • Ability to influence multidisciplinary teams and drive sustainable improvement
  • Must be 21 years of age or older
  • Preferred Qualifications
  • RN, LCSW, or other licensed healthcare professional
  • Certification in healthcare quality, risk management, or patient safety (CPHQ, ARM, etc.)

Why You’ll Love It Here (Full-Time Benefits)

• Multiple medical plan options, Vista Wellness (physician/pharmacy), Dental, Vision
• Generous PTO and paid holidays
• 401(k) with company contribution
• Life and disability coverage
• Tuition reimbursement up to $15,000
• Student loan forgiveness programs
• Opportunity to shape quality and safety in a mission-driven psychiatric hospital