Quality Improvement Director

Kitsap Mental Health Services; Bremerton (WA); On-site; USD 108,000 - 138,000; Full time

Benefits offered by this job

Health Coverage

PTO & Holidays

YMCA Membership

Life Insurance

Student Loan Assistance

403(b) Plan

EAP

Pet Insurance

Wellness App

Job summary

Kitsap Mental Health Services (KMHS) seeks a Quality Improvement Director to lead organization-wide quality initiatives, ensuring compliant, data-driven care that improves client outcomes and community health. The role partners with clinical and operational leaders to strengthen performance and foster a culture of continuous improvement.

The position emphasizes CARF/CCBHC readiness, evidence-based practices, and a collaborative leadership approach within KMHS’s Campbell Campus and remote work

Qualifications

• Bachelor's degree in nursing, social work, psychology, behavioral health or related field.
• Specialist— minimum 7 years of job-related experience.
• Master's degree in nursing, social work, psychology, behavioral health or related field preferred.
• CPHQ certification preferred. Formal Project Management training preferred.

Responsibilities

• Provide leadership and oversight for the agency's Quality Improvement Program in accordance with regulatory, accreditation, and certification requirements.
• Evaluate current methods of care delivery and collaborate with clinical and operational leaders to improve recovery-oriented, client-centered services.
• Use data, surveys, audits, and evaluation findings to identify opportunities for improvement across the organization.
• Partner with clinical leadership to develop outcome measures, reporting processes, and monitoring systems.
• Lead organizational readiness activities related to CARF, CCBHC, WAC, and other regulatory requirements.
• Guide quality improvement initiatives that align with agency policies, strategic priorities, and quality standards.
• Collaborate with organizational leaders to advance quality improvement, population health, and health equity strategies.
• Utilize Plan-Do-Study-Act (PDSA) cycles and other quality improvement methodologies to improve workflows and processes.
• Promote the use of evidence-based, data-informed, and recovery-oriented practices throughout the organization.
• Analyze policies, procedures, and systems to ensure ongoing compliance and readiness for future accreditation requirements.
• Provide quality improvement reports and recommendations to executive leadership, clinical leadership, and agency committees.
• Communicate quality data and improvement initiatives across the organization to support engagement and accountability.
• Coordinate quality committee meetings and ensure tracking of action items, documentation, and follow-up activities.
• Participate in organizational audits, evaluations, and reviews and develop corrective action plans when needed.
• Maintain current knowledge of regulatory requirements and emerging quality improvement practices.
• Oversee the Community Advisory Council, including quarterly meetings, reporting activities, and communication of recommendations to agency leadership and the Board of Directors.

Skills

Excellent communication

Confidentiality & diplomacy

Leadership

EMR proficiency

Education

Bachelor's degree (nursing, social work, psychology, behavioral health)

Master's degree (nursing, social work, psychology, behavioral health)

Tools

EMR system

Microsoft Office

Job description

Quality Improvement Director

Full-Time, On-Site in Bremerton, WA

Exempt (Salaried): $107,910.40 - $137,592.00 per year

Benefits at a Glance

• Comprehensive Coverage: Health, Dental & Vision
• Generous PTO: Up to 19 days + 2 mental health days + 10 holidays (pro-rated for part-time)
• Fully Paid YMCA Membership for you and eligible family members
• Company-Paid Life & Disability Insurance
• Student Loan Assistance & Professional Development
• 403(b) Retirement Plan with Company Contributions
• Employee Assistance Program (EAP)
• Pet Insurance
• Free Wellness App (2MorrowHealth)
• Collaborative, Supportive Team Environment

Kitsap Mental Health Services (KMHS) is seeking a Quality Improvement Director to lead quality initiatives across the organization. This position helps ensure services meet regulatory standards while supporting better outcomes for clients and the communities we serve. The role partners with leaders throughout KMHS to strengthen performance, advance health equity, and foster a culture of continuous improvement. If you're committed to improving systems that support quality care and organizational accountability, we welcome your application.

Primary Responsibilities:

• Provide leadership and oversight for the agency's Quality Improvement Program in accordance with regulatory, accreditation, and certification requirements.
• Evaluate current methods of care delivery and collaborate with clinical and operational leaders to improve recovery-oriented, client-centered services.
• Use data, surveys, audits, and evaluation findings to identify opportunities for improvement across the organization.
• Partner with clinical leadership to develop outcome measures, reporting processes, and monitoring systems.
• Lead organizational readiness activities related to CARF, CCBHC, WAC, and other regulatory requirements.
• Guide quality improvement initiatives that align with agency policies, strategic priorities, and quality standards.
• Collaborate with organizational leaders to advance quality improvement, population health, and health equity strategies.
• Utilize Plan-Do-Study-Act (PDSA) cycles and other quality improvement methodologies to improve workflows and processes.
• Promote the use of evidence-based, data-informed, and recovery-oriented practices throughout the organization.
• Analyze policies, procedures, and systems to ensure ongoing compliance and readiness for future accreditation requirements.
• Provide quality improvement reports and recommendations to executive leadership, clinical leadership, and agency committees.
• Communicate quality data and improvement initiatives across the organization to support engagement and accountability.
• Coordinate quality committee meetings and ensure tracking of action items, documentation, and follow-up activities.
• Participate in organizational audits, evaluations, and reviews and develop corrective action plans when needed.
• Maintain current knowledge of regulatory requirements and emerging quality improvement practices.
• Oversee the Community Advisory Council, including quarterly meetings, reporting activities, and communication of recommendations to agency leadership and the Board of Directors.

Minimum Qualifications:

EDUCATION: Bachelor's degree in nursing, social work, psychology, behavioral health or related field.

EXPERIENCE: Specialist— minimum 7 years of job-related experience.

Preferred Qualifications:

EDUCATION: Master's degree in nursing, social work, psychology, behavioral health or related field. EXPERIENCE: Experience supporting accreditation, regulatory, or patient safety initiatives.

• Four or more years of experience working in a healthcare setting, including hospitals, ambulatory care, community health, or managed care environments.
• Experience managing organizational risk and liability issues.
• Three years of management or supervisory experience.

LICENSE/CERTIFICATION: Certified Professional in Healthcare Quality (CPHQ) preferred. Formal Project Management training preferred.

Performance Requirements:

KNOWLEDGE:

• Knowledge of applicable clinical principles and practices.
• High-level knowledge of HIPAA and HITECH security regulations and other confidentiality and health information protections and their impacts in the clinical practice setting.
• Working knowledge of legal statutes and quality improvement strategies that govern clinical skills, clinical documentation, and agency operations.
• Federal, State, and Local regulations in the behavioral healthcare field.
• Familiarity with the Diagnostic and Statistical Manual, fifth edition (DSM-5) of Mental Health Disorders, the ASAM Criteria, and quality improvement processes at a systemic level.

SKILLS:

• Excellent communication and skill in establishing and maintaining effective working relationships with other employees, patients, organizations and the public.
• Confidentiality, diplomacy, and judgment in sensitive situations.

ABILITIES:

• Guide individuals and groups toward desired outcomes, setting high-performance standards and delivering leading quality services.
• Use adaptive leadership and a systems approach to implement effective, organization‑wide improvements.
• Establish and maintain long-term relationships with both internal and external customers, building trust and respect by consistently meeting and exceeding expectations. Ability to anticipate concerns and overcome objections.
• Articulate knowledge and understanding of organizational policies, procedures, and systems.
• Proficient in Microsoft Office applications and the ability to navigate an EMR system and other applications as required with minimal training.

Worksite-Specific Requirements:

WORKSITE #1: Campbell Campus

REQUIREMENTS: No additional requirements for this worksite location.

WORKSITE #2: Remote Worksite

REQUIREMENTS: Employees approved for remote work must maintain a safe, secure, and professional workspace with reliable internet, ensure confidentiality and compliance with KMHS policies (including HIPAA), and remain fully available and responsive during scheduled work hours.

Equipment Operated: Standard office equipment including computers, fax machines, copiers, printers, telephones, etc.

Work Environment: Office, remote workspace.

Mental/Physical Requirements:

• Sit, stand, and walk for extended periods.
• Lift, carry, push, and pull: Up to 10 pounds (frequently)
• Up to 20 pounds (occasionally)
• Up to 50 pounds (seldom)
• Use hands and arms for reaching, handling, and manipulation, including reaching above shoulder level.
• Have visual acuity and peripheral vision sufficient to read written materials and observe surroundings.
• Have hearing sufficient to communicate effectively.

Our recruitment processes are designed to prevent discrimination against our people regardless of gender identity or orientation, religion, ethnicity, age, neurodiversity, disability status, citizenship, or any aspect which makes someone unique.