What are the responsibilities and job description for the Director of Quality, Risk & Compliance position at Merraine Group?
Pontiac General Hospital is seeking a hands-on, strategic Director of Quality, Risk & Compliance to lead quality, patient safety, and regulatory functions within a growing behavioral health hospital.
This is a highly visible leadership role at a pivotal time of expansion. With plans to significantly increase census and scale operations, the Director will have the opportunity to build and strengthen systems, implement best practices, and drive a culture of safety and continuous improvement across the organization.
Reporting to executive leadership and partnering closely with the Chief Nursing Officer, this individual will play a key role in shaping quality outcomes and operational excellence.
Why This Role
- High-impact leadership role with direct access to executive leadership and the Board
- Growth environment with rapid expansion in patients and staff
- Collaborative, non-punitive culture focused on safety and improvement
- Entrepreneurial setting with the ability to build and influence systems
- Opportunity to help the hospital evolve into a Center of Excellence
Key Responsibilities
- Lead all aspects of Quality, Risk Management, and Compliance
- Oversee and evolve the QAPI program, including KPI tracking and performance improvement initiatives
- Ensure compliance with CMS and Joint Commission standards, lead survey readiness and audits
- Direct incident reporting, investigations, and root cause analyses (RCAs)
- Identify trends, mitigate risk, and implement corrective actions in real time
- Drive data collection, analysis, and reporting to inform decision-making
- Partner cross-functionally with clinical and operational teams to improve processes
- Provide education and training on quality, safety, and regulatory requirements
Ideal Candidate
- 3–5 years of experience in Quality, Risk, Compliance, or Performance Improvement in a hospital setting
- Strong understanding of behavioral health operations (required; must have BH exposure)
- Experience with QAPI, regulatory compliance, audits, and data analysis
- Familiarity with CMS and Joint Commission standards
- Proven ability to lead investigations and drive process improvement
Preferred:
- Clinical background (RN or similar)
- Advanced degree
- Experience with restraint/seclusion practices
- Knowledge of Michigan Mental Health Code and CON
Culture & Fit
- Self-starter who operates with urgency and accountability
- Collaborative and solutions-oriented (non-punitive approach to quality)
- Comfortable in a fast-paced, growth environment
- Strong communicator with a business-minded perspective
Organizational Snapshot
- Independent, for-profit behavioral health hospital
- Licensed for 124 beds (Adult, Geriatric, IDD)
- Current census ~20; scaling to 80–100 patients
- Team growing from ~60 to 170–200 FTEs
- Supported by engaged and accessible leadership
Salary : $135,000 - $175,000