EXECUTIVE DIRECTOR OF QUALITY MANAGEMENT - 80964

Executive Service

EXECUTIVE DIRECTOR OF QUALITY MANAGEMENT

Tennessee Department of Mental Health and Substance Abuse Services

Middle Tennessee Mental Health Institute

Nashville, TN

Annual Salary: $103,440.00 - $165,048.00

Closing Date: 09/24/2026

This position is in-person

Background Check:

This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position

Who we are and what we do:

The Tennessee Department of Mental Health and Substance Abuse Services serves as Tennessee's mental health and substance abuse authority. The Department operates four regional mental health institutes, partners with community providers, and supports quality behavioral health services statewide. Middle Tennessee Mental Health Institute is a 207-bed psychiatric hospital serving 18 counties in Middle Tennessee. MTMHI provides psychiatric treatment, forensic services, court-ordered evaluations, long-term and short-term care, and therapeutic treatment services.

Job Overview:

The Executive Director of Quality Management reports directly to the CEO and leads the hospital's Quality Management and Medical Records functions. This position oversees performance improvement, patient safety, risk management support, utilization review, survey readiness, quality reporting, corrective action follow-up, and medical records processes. The role works closely with hospital leadership, clinical teams, medical staff, department managers, and frontline staff to improve patient care, strengthen systems, and maintain compliance with Joint Commission accreditation, CMS Conditions of Participation, state licensure, and other applicable standards.

Key Responsibilities:

• Lead quality, patient safety, and performance improvement.

• Oversee hospital-wide quality activities by reviewing data, audits, peer review findings, incident trends, patient safety information, and performance improvement results to identify opportunities and support improvements in care, documentation, and operations.

• Support survey readiness, accreditation, and corrective action.

• Coordinate ongoing readiness for The Joint Commission, CMS, state licensure, health department, managed care organizations, and other external reviews.

• Support Focus Standards Assessments, survey activities, corrective action plans, Root Cause Analysis activities, facility rounding, completion tracking, and timely reporting to leadership.

• Manage Quality Management and Medical Records.

• Provide leadership, supervision, coaching, and support to Quality Management staff and supervisors.

• Oversee medical records, quality reporting, utilization review, risk management support, performance improvement tracking, committee documentation, hiring, retention, development, and performance management.

• Partner with hospital leaders and departments.

• Build effective relationships across the hospital to strengthen quality practices, documentation, process improvement, and patient safety.

• Participate in leadership meetings and committees, prepare materials, present findings, communicate trends, and support follow-up.

• Maintain policies, training, and documentation.

• Assist with policy development and revisions related to quality management, medical records, patient safety, and survey readiness.

• Train staff on updates and ensure reports, monitoring results, minutes, corrective actions, survey materials, and performance improvement documentation are maintained.

Minimum Qualifications:

• Possession of a bachelor's degree from an accredited college or university and at least five years of full-time professional mental health or quality management experience in a hospital or comparable setting, including at least two years of supervisory or managerial experience.

• Additional graduate coursework in hospital administration, public administration, business administration, or social or behavioral science may substitute for required experience on a year-for-year basis, up to two years. There is no substitution for the required two years of supervisory or managerial experience.

Preferred Experience:

• Experience in hospital quality management, performance improvement, Joint Commission survey readiness, CMS Conditions of Participation, psychiatric hospital or behavioral health operations, medical records oversight, patient safety, risk management, Root Cause Analysis, corrective action planning, or supervision of professional staff is preferred.

Ideal Candidate:

• The ideal candidate has experience leading quality management, performance improvement, patient safety, medical records, utilization review, or related functions in a hospital or behavioral health setting. The successful candidate will be skilled in working with clinical and administrative leaders, reviewing data and documentation, preparing for surveys, developing corrective action plans, coaching staff, and supporting continuous improvement.Strong leadership, sound judgment, clear communication, attention to detail, and the ability to translate standards and data into practical improvements are essential.

Pursuant to the State of Tennessee's Workplace Discrimination and Harassment policy, the State is firmly committed to the principle of fair and equal employment opportunities for its citizens and strives to protect the rights and opportunities of all people to seek, obtain, and hold employment without being subjected to illegal discrimination and harassment in the workplace. It is the State's policy to provide an environment free of discrimination and harassment of an individual because of that person's race, color, national origin, age (40 and over), sex, pregnancy, religion, creed, disability, veteran's status or any other category protected by state and/or federal civil rights laws.