Director of Program Quality and Compliance

About our Company:

Envoi Associates is one of Tennessee’s leading providers of services and support to youth and young adults with exceptional needs. Our talented and well-trained professionals and clinicians believe in a person-centered and holistic approach to support and serve the youth in our care. We have 50 combined years of experience in the human services field and currently offer services in Tennessee and Colorado. Our goal is to provide quality services, with our signature wrap-around approach, which includes expert case management and mental health treatment, to allow each youth to experience a higher quality of life.

Envoi Associates provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Position Summary

Benefits:

• Flexible schedule
• Partial company paid major medical heath insurance for employee only plans
• Dental and Vision insurance
• 2 weeks paid vacation, 1 week paid sick awarded upon hire
• 16 paid holidays each year
• Yearly Performance Reviews
• New company laptop, iPhone work cell
• Mileage reimbursement $.50 per mile
• MANY more!!!

The Director of Program Quality & Compliance leads the enterprise Quality/Compliance system across all programs and provider networks in their designated state. This role designs the QAPI plan and KPIs; ensures regulatory and accreditation readiness (e.g., CARF, state licensing/Medicaid); oversees incident and risk management; and drives corrective actions that improve safety, program performance outcomes, and documentation integrity. The Director partners with leadership to make data-driven improvements, ensures non-retaliatory reporting channels, and communicates performance through a recurring dashboard and reviews. Finally, the Director ensures the seamless coordination of program expansion, promotes operational efficiency, and safeguards the regulatory stability of programs.

Minimum Requirements

· Master’s Degree in Social Work, Psychology, Public Administration, Project Management, Health/Human Services, or equivalent in closely related field.

· 7 years in human services/behavioral health with 3 years leading QA/Compliance/QAPI across multiple programs or sites.

· Experience leading multi-state compliance or provider networks.

· Hands-on accreditation oversight and state Medicaid/HCBS compliance.

· Demonstrated success building or running a quality management system (QMS/QAPI) and corrective action programs (CAPA).

· Technical: intermediate/advanced Excel or BI (Power BI/Tableau), EHR proficiency, audit/monitoring tools, root-cause methods.

· Regulatory Knowledge: HIPAA, HCBS settings rules, Medicaid waiver requirements, incident reporting, state licensing.

· Must be able to travel to assigned regions, including the Company’s corporate office.

· Valid driver’s license/insurance/MVR as required by role.

Job Qualifications

· Possess professional knowledge and abilities in communication, as well as building and maintaining relationships.

· Passion and commitment to support people with dignity and acceptance of the Company’s person-centered philosophy.

· Must have solid computer and organizational abilities including planning, delegating, program development, and task facilitation with the ability to manage multiple projects at one time.

· Be able to work independently and meet agency deadlines and policy requirements.

· Independent in problem-solving and decision-making in well thought out ways.

· Elevated level of skill and expertise in leading personnel who support people served by the Company.

· Ability to take initiative, work independently, take ownership of projects, and be a dedicated team player.

· Possess leadership and problem-solving skills with the ability to respond to problems/crises in a calm demeanor and independently guide management personnel in doing so.

· High ethical standards with analytical ability, good judgment, and operational focus.

· Ability to accept feedback and know when it is appropriate to ask for guidance or clarification.

· Possess higher-level decision-making, analytical, creative, innovative, and critical thinking skills in order to grow and contribute to the Company’s strategic vision.

· Commitment to assuring program compliance with all applicable laws and regulations.

· Ability to be a supportive colleague and demonstrate patience and respect towards staff at all levels of the Company; promote cooperative working relationships and a positive team atmosphere, both internally and externally with providers, families, coworkers, and the people we support.

· Familiarity with applicable federal, state, and local rules and regulations. Willingness and ability to expand this knowledge base to accommodate and contribute to program expansion.

· Exceptional spoken/written communication, organizational, and time management skills.

Essential Functions and Responsibilities (included, but not limited to)

· Comply with the federal Confidentiality Law and HIPAA regulations/guidelines to protect the confidentiality of all persons supported.

· Follow and exemplify the Company’s vision, mission, and values.

· Exercise discretion and confidentiality with sensitive company information.

· Serve as the Company’s designated Compliance Officer.

· Chair or co-chair the Compliance & Quality Assurance Committee.

· Accreditation & Licensing Readiness

· Serve as accreditation lead: gap assessments, evidence files, mock surveys, and post-survey plans.

· Maintain a regulatory change log; translate changes into policy, training, and EHR/process updates.

· Compliance Oversight & Quality Management

· Design, own, and continuously improve the Company’s quality management program: annual plan, goals, indicators, audit/monitoring calendar, and reporting cadence.

· Define enterprise KPIs (e.g., documentation timeliness, incident rates, grievances, access/wait times, outcomes) and publish a monthly quality dashboard.

· Lead root-cause analyses (RCA) and Corrective/Preventive Actions; verify effectiveness and close actions on time.

· Operate the issue-intake/hotline; ensure non-retaliation and timely triage/investigation.

· Establish the annual compliance workplan (audits, monitoring, education); report progress to leadership.

· Ensure all programs comply with federal, state, and local regulations, licensing requirements, and accreditation standards.

· Develop, implement, and monitor policies and procedures to maintain regulatory and ethical standards in service delivery.

· Assist with the organization of Company policies and procedures, including numbering and tracking of developed policies, storage of current and archived versions, documenting meetings minutes, etc.

· Conduct regular audits, site visits, and program evaluations to assess compliance, quality of care, and risk mitigation.

· Lead investigations into compliance concerns, incidents, and grievances, ensuring appropriate corrective action.

· Maintain up-to-date knowledge of changes in laws, regulations, and best practices affecting applicable programs.

· Participate in the review and resolution of all formal complaints by persons served; conduct a documented analysis of such complaints.

· Monitor quality of services through ongoing solicitation and review of input from clients, employees, and stakeholders.

· Conduct regular audits of client files and contractor (e.g., foster homes, family model providers) files across programs and follow up with program leadership to obtain/correct missing, incorrect, or expired items.

· Monitor and analyze service delivery to ensure alignment with organizational mission, strategic goals, and industry best practices.

· Conduct internal agency self-assessments of all programs to ensure implementation of systems to support compliance.

· Analyze program performance data to identify areas for improvement and implement quality enhancement initiatives.

· Create and disseminate reports on outcomes of agency self-assessments.

· Develop and oversee corrective action plans to address identified deficiencies or areas of non-compliance.

· Collaborate with leadership to ensure the integration of compliance measures into program development and expansion.

· Provide guidance and support to program staff to reinforce a culture of compliance and ethical service delivery.

· Assist in the development, ongoing monitoring, and documentation of objectives and performance indicators for each program.

· Training & Competency

· Own the annual compliance and quality training plans (role-based, program-based); ensure 100% completion and competency checks.

· Provide focused coaching following audits, incidents, or notable trends.

· Stakeholder & Regulatory Engagement

· Lead client/guardian/stakeholder feedback loops (surveys, focus groups) and convert insights into measurable QAPI actions.

· Serve as regulatory point-of-contact; coordinate responses to audits and requests; present quality/compliance performance to leadership.

· Incident, Risk, & Safety Management

· Own the Company’s Risk Management, Corporate Compliance, and Business Continuity/Disaster Recovery Plans.

· Chair or co-chair the Incident Review Committee; track incident rates, closure times, and trends; escalate sentinel events immediately.

· Collaborate with program leadership to develop annual written critical incident analysis.

· Coordinate Business Continuity/Disaster Recovery tests.

· Oversee health & safety spot checks for offices/residences (as applicable).

· Develop and enforce protocols for incident reporting, response, and resolution.

· Assess potential risks in service delivery and implement proactive strategies to minimize legal and operational exposure.

· Ensure proper documentation and investigation of critical incidents, with follow-up actions as necessary.

· Oversee health and safety initiatives across programs.

· Financial & Contract Integrity

· Monitor billing compliance (claims accuracy; fraud/waste/abuse prevention) with Finance/RCM; trend denials and lead corrective actions when documentation causes denials.

· Ensure adherence to contract/funding requirements (documentation, ratios, service definitions, reporting).

· Own the Company’s Accessibility; Cultural Competency, Diversity, Equity, and Inclusion; Technology and Systems; and Strategic plans.

· Perform other such duties as assigned by the Vice President of Operations, or designee, that are within the scope of the position, as well as those reflective of professional experience, education, and ability.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Physical Demands and Working Conditions:

· Physical Requirements - Requires repetitive manual and finger dexterity and eye-hand coordination; requires the ability to use all office equipment, and the ability to lift/carry up to 30 pounds using appropriate body mechanics.

· Visual, Hearing and Communication Requirements - Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Must be able to communicate verbally with all staff, vendors, clients, and stakeholders.

· Pressure Factor – May require working under stressful conditions at times and handling emergencies. Working conditions may be noisy with fluctuating indoor temperatures. There will be pressure at times to meet scheduled appointments and deadlines and manage crisis situations.

Pay: $80,000.00 - $100,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Referral program
• Vision insurance

Education:

• Master's (Preferred)

Experience:

• human services/behavioral health: 7 years (Required)

Work Location: Hybrid remote in Nashville, TN 37201

Salary : $80,000 - $100,000