Posted: Jun 29, 2021

Director of Quality Improvement (Comm Svs Bd Plng/Dev Dir)

Application Deadline: Jul 23, 2021
Health Services

Responsible for the CSB's system-wide development and implementation of continuous quality improvement, quality assurance, risk management, and human rights programs to inform and impact all clinical and administrative services. Guides the integration of the principles of continuous quality improvement into the oversight and delivery of clinical services and administrative operations, leads the agency’s quality assurance functions to maintain compliance with federal and state laws, and provides effective risk management activities within the continually evolving and rapidly changing behavioral health and developmental disability field. Reports to the CSB Deputy Director of Administrative Operations for all day-to-day administrative matters relating to quality improvement, quality assurance, risk management, and human rights. Collaborates directly and frequently with the executive staff and the CSB Board of Directors on salient quality issues.

The ideal candidate will be able to quickly identify quality improvement, quality assurance, risk management, and human rights issues, develop strategies, and formulate plans to mobilize resources that can be clearly communicated to the executive staff and the CSB Board of Directors. This candidate will have expertise and knowledge of\in:

  • Leadership;
  • Collaboration;
  • Planning;
  • Program Management;
  • Outstanding skills and experience in quality improvement, quality assurance, and risk management; and
  • Implementation of strategic initiatives.

Note:  For more information about the position and the CSB, please view our informational brochure (Download PDF reader)


Illustrative Duties

(The illustrative duties listed in this specification are representative of the class but are not an all-inclusive list. A complete list of position duties and unique physical requirements can be found in the position job description.)

  • Designs, develops and implements a compliance program across all services;
  • Provides synergistic supervision a team of  compliance and risk management staff;
  • Develops, initiates, maintains, manages and revises policies, regulations, and procedures for the general operation of the Compliance Program and related agency activities to prevent illegal, unethical, or improper conduct;
  • Chairs the Executive staff Compliance Committee, CSB's Ethics Committee and Patient Safety Risk Management Committee;
  • Independently collaborates with other County departments e.g., Risk Management, Internal Audit, Administration for Human Services, Human Resources to address and resolve any compliance issues;
  • Reviews and updates agency Standards of Conduct in concert with County standards to ensure continuing currency and relevance in providing guidance to management and employees;
  • Consults with the County Attorney as needed to address legal aspects of agency compliance issues;
  • Provides direction and investigative direction  for issues through the County's  compliance Hotline as it relates to the CSB;
  • Develops policies and regulations that encourage open communication to enable managers and employees to report suspected fraud and other improprieties without fear of retaliation;
  • Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the County's Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures;
  • Independently investigates and acts on matters related to compliance, with authority and flexibility to design and coordinate internal investigations (e.g., responding to reports of problems, 'hot-line' calls, or suspected violations) and any resulting corrective actions with all CSB and other County departments, directly operated programs, and contract providers, and if appropriate, independent contractors;
  • Works directly with the CSB Executive Director, and/or the CSB Governing Board on matters of compliance and risk management;
  • Develops and manages agency-wide comprehensive audit and monitoring processes and oversees development of systematic audit and monitoring processes;
  • Coordinates compliance review, monitoring and audit activities, and facilitates systematic program and site reviews and coordination of internal audits;
  • Develops/implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future;
  • Develops and oversees a system for uniform handling and documentation of violations; Assists, coordinates, and helps deliver a multifaceted educational and training program that focuses on the elements of the compliance program, and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent federal and state standards;
  • Collaborates with other County purchasing and contract oversight departments to ensure that contractors and agents who furnish services to the CSB system are aware of the requirements of the compliance program with respect to integrity, coding, coverage, billing, and marketing.


Required Knowledge Skills and Abilities

(The knowledge, skills and abilities listed in this specification are representative of the class but are not an all-inclusive list.)

  • Thorough knowledge of principles and practices of a health care compliance program;
  • Knowledge of US Sentencing Commission and US Department of Health and Human Services Office of Inspector General guidelines and standards for effective compliance programs;
  • Ability to conduct comprehensive program analysis, ability to devise, develop and implement sound management policies and procedures;
  • Ability to write and speak effectively;
  • Ability to work effectively under pressure and meet established deadlines;
  • Ability to maintain good working relationships with employees, public officials and the general public;
  • Ability to supervise and provide leadership to directors of service lines.


Employment Standards

Any combination of education, experience, and training equivalent to the following: 
(Click on the aforementioned link to learn how Fairfax County interprets equivalencies for “Any combination, experience, and training equivalent to”)
Graduation from an accredited college or university with a bachelor's degree in related fields such as, psychology, social work, nursing, public health, public administration, public policy, health care administration or related field; plus at least five years of experience in a large organization with increasingly professional responsibilities in behavioral health care compliance, HIPAA, operations, clinical, financial and quality assurance to include at least five (5) years of supervisory experience.

  • Certification in Health Care Compliance with either the Health Care Compliance Association (HCCA), Society of Corporate Compliance and Ethics (SCCE) is required and in good standing. Such as:
    • Certified Health care Privacy Compliance (CHPC)
    • Certified Health Care Compliance (CHC)
    • Certified Compliance and Ethics Professional (CCEP)
  • Valid driver's license.

Some positions within this classification will require additional certifications and licenses, as defined by the position description and posted in job announcements.
The appointee to this position will be required to complete a criminal background check, a Child Protective Services Registry check, credit check, driving record check, and sanction screening to the satisfaction of the employer. A TB screening upon hire.

This position is emergency/essential services personnel. (Required to report for duty during inclement weather and/or other emergencies).    


  • Master's degree preferred.
  • Ten years of increasing clinical, managerial, and operational experience with quality management in a health care setting to include behavioral health and intellectual disabilities services.
  • Knowledge of the U.S. Sentencing Commission and the U.S. Department of Health and Human Services of the Office of the Inspector General's guidelines and standards for effective compliance programs.

Ability to use keyboard driven equipment, communicate clearly orally and in writing, and attend offsite meetings.  All duties performed with or without reasonable accommodations.

Panel Interview and may include a practical exercise.