Director of Quality

SIERRA VISTA; Johnstown (CO); On-site; USD 95,000 - 115,000; Full time

Benefits offered by this job

Medical plan options

PTO and paid holidays

401(k) with company contribution

Life and disability coverage

Tuition reimbursement up to $15,000

Student loan forgiveness programs

Job summary

SierraVista is seeking a Director of Quality to provide strategic and operational leadership for quality improvement, patient safety, and risk management across our psychiatric hospital. This role ensures care delivery meets regulatory standards while fostering a culture of continuous improvement and patient-centered care.

The position requires 5+ years of healthcare quality leadership experience, with strong knowledge of behavioral health standards, CMS participation, and data analysis

Qualifications

• 5+ years of healthcare quality leadership experience, preferably in a psychiatric or behavioral health hospital.
• Strong working knowledge of Joint Commission behavioral health standards and CMS Conditions of Participation.
• Experience with data analysis, regulatory readiness, and survey management.
• Ability to influence multidisciplinary teams and drive sustainable improvement.
• Preferred qualifications include RN, LCSW, or other licensed healthcare professional and certification in healthcare quality or risk management.

Responsibilities

• 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.

Skills

Data analysis

Regulatory readiness

Patient safety frameworks

Leadership

Education

RN or equivalent licensed healthcare professional

CPHQ/ARM or similar certification

Job description

Pay: 95K-$115K
Location: 4770 Larimer Pkwy, Johnstown, CO 80534
Schedule: Day Shift
Leadership: On-Call as Needed

About Us

At SierraVista, our mission is to inspire hope and deliver holistic care to those facing acute psychiatric conditions and substance use disorders. We provide a safe, healing environment where patients gain the life skills needed to achieve long-term recovery and independence.

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