SR Director - Quality, Risk and Compliance

MISSION: To inspire health, wellbeing, and humanity in our community, through all of life’s stages.

PAY AND BENEFITS: Tepeyac offers a full compensation package to all full-time employees. Benefits include medical, dental and vision insurance, a flexible spending account, a 401k, disability insurance paid for by Tepeyac, twelve paid holidays in 2026, approximately four weeks of vacation time off each year, and over one week of sick leave annually.

The salary range for the Senior Director of Quality, Risk, and Compliance is $112,961 - $131,969/annually.

JOB SUMMARY: The Senior Director for Quality, Risk, and Compliance (Senior QRCD) is the leader of the QRC department and is responsible for providing leadership and expertise to ensure continuous compliance with Federal, State and local regulatory requirements, and to ensure the delivery of safe, high-quality patient care services. This role is responsible to lead the organization in safety practices, systems thinking, accountability and good resource stewardship, and will socialize best practices throughout the organization. This position will supervise the Data Analyst role.

EDUCATION AND EXPERIENCE

A combination of formal education and years of experience related to compliance, quality and/or risk management will be considered. A minimum of 5 years’ experience in regulatory compliance, quality and/or risk management required; 10 years preferred.

Certification in Healthcare Compliance required (HCCA preferred, other certifications will be considered). May obtain certification within the first 6 months of employment. Additional certifications in Risk Management and Clinical Quality Management desired.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Program Oversight

Direct, ensure the timely implementation of required activities, and monitor the effectiveness of the Compliance, Risk Management, and Quality Programs at Tepeyac, taking appropriate steps to continuously improve program efficiency and impact.

Provide guidance and training to and collaborate extensively with executive and leadership staff as needed to achieve the objectives of effective compliance, risk management, and quality programs.

Report to the Board of Directors (BOD) on a regular basis on the effectiveness of the Compliance, Risk Management, and Quality Programs. Provide guidance and training to BOD related to organizational policies and federal, state, and local laws and regulations, including HRSA Health Center Program requirements.

Compliance

Serves as organization’s HIPAA Privacy Officer and Compliance Officer.

Serves as subject matter expert on corporate and healthcare compliance for the organization.

Oversee a Corporate Compliance Program and ensure staff, Board members, and others associated with Tepeyac receive the appropriate training and education.

Develop and maintain a written Corporate Compliance Plan, Standards of Conduct, and annual evaluation of the plan’s effectiveness; ensure all elements of the Corporate Compliance Program are addressed, including Conflict of Interest Management.

Oversee investigations relating to reports of known or suspected violations of the Corporate Compliance Program or the Code of Conduct.

In consultation with the Chief Executive Officer (CEO), submit mandatory notification of known or suspected corporate compliance violations to the appropriate regulatory agencies.

Develop and maintain policies and procedures for Tepeyac, overseeing a document management system of Tepeyac’s policies and procedures to ensure timely review and approval by department leaders and the BOD.

Develop and maintain up-to-date knowledge of corporate compliance requirements and related law and regulations as mandated or recommended by the OIG, CMS, HIPAA, HRSA, FTCA, and other agencies, and ensure Tepeyac maintains compliance. Attend external corporate compliance trainings provided by NACHC and/or other agencies.

Partner with the HIPAA Security Officer to ensure organizational compliance with federal, state, and local laws governing access, confidentiality, privacy, and security of Protected Health Information (PHI) and Patient Health Records.

Maintain knowledge of Tepeyac’s grants requirements, contracts, and organizational strategies to assess impact on compliance and risk program accountabilities. This includes Tepeyac’s Federal Health Center Program grant. Ensuring Health Center Program compliance, including oversight of HRSA Operational Site Visits (OSV) and annual Uniform Data System (UDS) reporting.

Serve as a resource and guide to all staff and especially to leadership staff on compliance, quality, and risk management matters through education, data reporting, and effective communication.

Perform and support external and internal compliance audits; ensure corrective action plans are documented in a timely manner and effectively implemented.

Work with Operations Leadership and IT Leadership to ensure that Emergency Preparedness & Management, Continuity of Operations, and Disaster Recovery Plans meet CMS and HRSA requirements. Ensure these plans are implemented per CMS and HRSA requirements by monitoring the planned activities.

Provide guidance to HR team to ensure credentialing and privileging processes are completed according to the Health Center Program requirements and internal procedures. Establish and maintain monitoring system to confirm compliance on a regular basis.

While the Senior QRCD reports to the Chief Operations Officer (COO), the Senior QRCD has a dotted line directly to the CEO and the BOD to address important compliance concerns, should they arise.

Quality

Oversee an organization-wide Quality Improvement/Quality Assurance (QIQA) program inclusive of all staff.

Develop and implement Tepeyac’s annual QIQA Plan in accordance with HRSA’s requirements and in collaboration with the Chief Health Officer (CHO), COO, Behavioral Health Director, Dental Director, and other clinic and administrative leadership staff. This includes facilitating committee meetings, quarterly reporting to the BOD, and presentation of an annual report to the board.

Lead QIQA activities, including data reporting and evaluation to performance of previous year’s goals, quarterly status reports, and future performance goals, and updating of policies and procedures, as necessary.

Serve as the administrative quality liaison to external parties administrating value-based payment and shared savings contracts.

Supervise the Data Analyst, ensuring all job functions are supported.

Foster and develop a just culture for employees, in which the regular reporting of incidents and workflow issues is expected and comfortable for employees regardless of their role, to facilitate a culture of continuous improvement and a safe environment for employees and patients.

Model and lead the organization in identifying and learning best practices for safety, systems thinking, accountability, good resource stewardship, and socialize best practices for process improvement.

Provide ongoing development of quality improvement strategies and identification of opportunities for improvement.

Oversee and support all QI projects in collaboration with respective team members, delegating as applicable.

Provide project management and development across the organization, in collaboration with key partners, to lead quality initiatives.

Direct and partner with the Data Analyst and organizational leadership to develop and maintain a performance measurement work plan and reporting calendar to ensure timely data collection, aggregation, analysis, and reporting of established performance measures related to key operational and clinical processes and outcomes.

Ensure, in collaboration with Data Analyst and IT, the management of electronic storage of quality improvement reports to promote ongoing access for key stakeholders.

Risk Management

• Serves as organization’s Risk Manager and Malpractice Claims Manager (responsible for administrative management of FTCA Malpractice Claims).
• Oversee an organization-wide risk management program.
• Develop and implement Tepeyac’s written Risk Management Plan. This includes facilitating committee meetings, quarterly reporting to the BOD, and presentation of an annual report to the BOD.
• Develop and maintain policies and procedures related to the Risk Management Program.
• Lead an annual Organizational Risk Assessment to identify specific high-risk areas of the organization.
• Responsible for the daily monitoring and oversight of risk management activities.
• Model and lead staff in identifying potentially harmful environmental and system issues and develop processes for mitigating risk in a timely manner.
• Oversee and evaluate processes for internal incident reporting.
• Collaborate with the CHO in the investigation of clinical events including sentinel events, sentinel event near misses, and significant adverse events; lead and/or participate in the development of root cause analyses as directed by the CHO.
• Work with legal counsel, in collaboration with the CEO, when appropriate.
• Monitor patient experience data, managed by Patient Services Manager and Practice Manager, and support in addressing issues related to reputational risk.
• Partner with Director of Development and Communication to manage reputational risk in correspondence with the public and media.

OTHER DUTIES AND RESPONSIBILITIES

• Serves as a senior leader in the organization and provide guidance to Executive Team on compliance, risk, and quality during Executive Team meetings and when otherwise required.
• Serves as a member of the organization’s Incident Command and may serve as Incident Commander during an emergency as determined by the line of succession.
• Serves on various committees where compliance, quality, risk management oversight and collaboration are needed and requested.
• Attends required internal meetings, trainings, and events.
• Other duties as assigned.

KNOWLEDGE, SKILLS & ABILITIES

• Experience managing projects, including development and implementation of policies, procedures, and workflows.
• Experience with Federal Programs such as Federally Qualified Health Centers (FQHC), 340B program, FTCA, HIPAA.
• Demonstrated leadership skills including excellent oral and written communication skills.
• Strong knowledge of healthcare clinical fundamentals, patient safety standards, and performance improvement standards.
• Strong knowledge of CQI tools and techniques, ability to perform data analytics, and lead performance improvement teams.
• High ethical standards and an appropriate professional demeanor.
• Ability to prioritize and organize workload, balancing multiple projects as well as competing priorities and demands; ability to work under pressure in a fast-paced environment.
• Excellent interpersonal skills to work effectively with all levels of employees, management, regulators, and vendors.
• Ability to maintain confidentiality and navigate sensitive matters related to organization, employee, and senior leadership situations.
• Collaborative leadership skills and ability to influence and work well with others.
• Ability to focus on detail and explain detailed information in a manner understandable to various target audiences.
• Excellent communication, assessment, and problem-solving skills.
• Thorough knowledge of and ability to reinforce HIPAA Privacy requirements.

PRINCIPAL WORKING RELATIONSHIPS

Executive and Leadership staff including Board of Directors

Data Analyst

Senior IT Manager and HR Director

Patient Services Manager, Practice Manager, and Grants & Contracts Manager

External Legal Counsel and State and Federal governmental entities

Colorado Community Health Network, Community Members, and other Healthcare Providers/Practices

Vaccinations: Tepeyac Community Health Center employees are required to provide valid proof of vaccination prior to starting employment, subject to the requirements of the American with Disabilities Act (42 U.S.C. § 12101 et seq..), Title VII of the Civil Rights Act (42 U.S.C. § 2000e et seq.), the Colorado Anti-Discrimination Act (C.R.S. § 24-34-401 et seq.), and any other relevant federal or State law. This requirement includes volunteers. The full list of required vaccinations can be found on our Tepeyac Careers page.

About us. For over 30 years, Tepeyac Community Health Center has been committed to providing integrated physical and behavioral health care to over 8,000 individuals across the Denver metro area. Tepeyac has distinguished itself as a dynamic organization dedicated to eliminating health disparities, particularly among Latino and immigrant communities. Tepeyac maintains an unwavering commitment to effective patient care, continual quality improvement, and the consistent treatment of each patient with the highest level of respect and compassion.

Over the next 3-5 years, Tepeyac seeks to continue to expand medical, dental, behavioral, and pharmacy services, providing culturally relevant high-quality care.

All employees of Tepeyac Community Health Center are required to be Colorado residents at time of hire and through their duration of employment.