Y-Team Director

Corporate-level quality and compliance professional responsible for evaluating, validating, and strengthening regulatory compliance across the organization’s behavioral health facilities. This highly visible, hands-on role requires regular travel to company facilities to conduct comprehensive site surveys, Conditions of Participation (CoP) audits, medical record and chart reviews, focused compliance audits, and follow-up validation activities.

Responsibilities

• Conduct comprehensive on-site facility surveys and regulatory compliance audits.
• Perform Conditions of Participation (CoP) reviews, medical record/chart audits, and other focused compliance assessments.
• Evaluate facility compliance with applicable CMS, federal, state, accreditation, and organizational requirements.
• Identify deficiencies, areas of regulatory risk, and opportunities for performance improvement.
• Review and validate facility-reported compliance data, corrective actions, and supporting documentation.
• Conduct follow-up audits to ensure corrective actions have been fully implemented and sustained.
• Assist facility leadership and the Corporate Quality Director with the development, implementation, monitoring, and validation of Plans of Correction (POCs).
• Evaluate whether corrective actions effectively address the root cause of identified deficiencies.
• Provide education, guidance, and support to facility leadership regarding regulatory expectations, survey readiness, documentation, and compliance.
• Monitor trends and recurring deficiencies across facilities and communicate findings to Corporate Quality leadership.
• Support facilities before, during, and following regulatory and accreditation surveys.
• Maintain accurate documentation of audit findings, recommendations, follow-up activities, and compliance validation.
• Work collaboratively with clinical, administrative, nursing, and corporate leadership to promote continuous improvement and accountability.
• Maintain knowledge of current regulatory requirements and communicate applicable changes to leadership.
• Travel regularly to company facilities based on audit schedules, survey readiness, compliance concerns, and Plan of Correction needs.

Requirements

• Minimum of 5–7 years of progressive healthcare leadership experience, preferably within behavioral health, inpatient psychiatric, or acute healthcare settings.
• Experience with healthcare quality, regulatory compliance, accreditation, auditing, survey preparation, or performance improvement is strongly preferred.
• Strong knowledge of healthcare regulatory and compliance requirements, including CMS Conditions of Participation and State Operations Manual (SOM) guidance.
• Experience with regulatory surveys, compliance audits, Plans of Correction, and survey readiness.
• Strong medical record and clinical documentation auditing skills.
• Ability to identify compliance deficiencies and determine whether corrective actions are effective and sustainable.
• Strong analytical and problem-solving abilities.
• Excellent verbal and written communication skills.
• Ability to provide constructive education and guidance to facility leadership.
• Strong organizational skills with the ability to manage multiple facilities, deadlines, and competing priorities.
• Ability to work independently while maintaining effective communication with Corporate Quality leadership.
• Ability to adapt quickly to changing schedules, priorities, and facility needs.
• Strong interpersonal skills and the ability to work effectively with clinical and administrative leadership.
• Proficiency with Microsoft Office applications, including Excel, and experience utilizing SharePoint or similar platforms.
• Ability to read, interpret, and apply regulatory standards, policies, procedures, and written guidance.
• Commitment to maintaining high standards of quality, compliance, accountability, and continuous improvement.
• Current clinical licensure in the applicable state of practice is preferred.

Schedule

• Regular travel between company facilities, with an expectation of being onsite approximately four days per week.
• Works in both office and inpatient behavioral healthcare environments and may enter patient care areas while conducting audits and surveys.
• Must follow all applicable facility safety, infection prevention, confidentiality, HIPAA, and security requirements while on-site.
• Requires the ability to sit, stand, and walk for extended periods; utilize a computer; review electronic and paper medical records; and communicate effectively with employees and leadership.
• Must maintain all required health documentation, including tuberculosis screening/testing and other documentation required by organizational policy or applicable regulatory requirements.