Director of Quality, Risk & Compliance
Merraine Group, Pontiac, MI, United States
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
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