Director of Systems Quality

Job Summary/Objective:

The Director of Systems Quality is responsible for the design, implementation, and oversight of organization-wide quality assurance systems that ensure the consistent delivery of safe, effective, and compliant behavioral health services. This role prioritizes performance monitoring, risk identification, and continuous system improvement across all service lines in Summit Pointe. The Director leads the development and execution of quality assurance strategies that align with requirements from the Michigan Department of Health and Human Services (MDHHS), regional oversight entities such as SWMBH, and federal CCBHC standards. This position ensures that clinical and operational practices meet defined standards through structured auditing processes, data validation, corrective oversight, and performance reporting.

In collaboration with clinical, operational, and executive leadership, the Director of Systems Quality promotes a culture of accountability, data-informed decision-making, and continuous improvement to enhance customer outcomes, mitigate risk, and sustain regulatory compliance.

Essential Duties and Functions:

• Leads the development, implementation, and ongoing refinement of the organization’s Clinical Quality and Utilization Management Plan, ensuring alignment with CCBHC, MDHHS, Medicaid, and accreditation standards.
• Serves key role in the support and implementation of performance improvement initiatives. Achieved via training and implementation of the Summit Pointe Management System, utilizing Six Sigma and Lean Management principles including oversight of Kaizen Events and data management.
• Designs and oversees quality performance monitoring processes across all programs and services.
• Conducts routine and targeted audits (e.g., documentation, service delivery, billing integrity, regulatory compliance) to ensure adherence to established standards and identify areas of risk.
• Establishes and monitors key performance indicators (KPIs) and quality metrics to evaluate service effectiveness, access, timeliness, and outcomes.
• Analyzes data trends to identify systemic issues, compliance risks, and performance gaps; develops actionable recommendations for improvement.
• Oversees the timely implementation, monitoring, and resolution of identified deficiencies.
• Ensures organizational readiness for external reviews, site visits, and audits conducted by MDHHS, SWMBH, and other regulatory or accrediting bodies.
• Collaborates with program leadership to operationalize quality standards and integrate quality monitoring processes into daily service delivery.
• Provides training, technical assistance, and consultation to staff and leadership regarding quality standards compliance and expectations.
• Monitors data integrity and reliability within the Electronic Medical Record (EMR) and reporting systems to support accurate internal and external reporting.
• Prepares and delivers regular reports to the Chief Clinical Officer and Executive Team summarizing quality performance, risks, and improvement initiatives.
• Maintains compliance with all applicable confidentiality and privacy regulations, including HIPAA and 42 CFR Part 2.
• Participates in organizational performance improvement initiatives and strategic planning efforts related to quality and compliance.
• Other duties as assigned.

Qualifications:

• Master’s degree in behavioral health, public health, or related field.
• Licensure not required; relevant experience in behavioral health systems preferred.
• Experience in quality assurance, compliance, auditing, or performance improvement in behavioral health settings.
• Preferred certification or training in Performance Improvement (PI), Continuous Quality Improvement (CQI), Lean/Six Sigma, with a Green Belt or higher, or Project Management.
• Knowledge of CCBHC standards, Michigan Medicaid requirements, and Community Mental Health (CMH) systems.
• Strong data analysis skills with the ability to interpret trends and drive improvement.
• Demonstrated ability to manage multiple priorities and projects effectively.
• Strong communication, collaboration, and problem-solving skills, with proficiency in standard technology and EMR systems.

Benefits:

• Premium health and vision within 30 days of hire
• Company sponsored Health Reimbursement Account
• Company paid short and long-term disability
• Employee assistance program
• 401(K) match up to 5% after one year of service
• Social security alternative contributions
• Free YMCA membership
• Generous paid time off
• 14 paid holidays
• Continuing education reimbursement
• Licensure study materials and exam reimbursement

Trauma Informed System of Care:

A trauma-informed approach to service delivery emphasizes physical and emotional safety, choice, empowerment, and trustworthiness for customers. The impact of trauma is broad and touches many life domains. Participation is mandatory for activities required for Summit Pointe to become a “Trauma Informed System of Care.”