Quality & Compliance Manager

2 days ago

San Antonio, TX, United States Nexus Health Systems Full time
Quality & Compliance Manager

Nexus Neurorecovery Center - San Antonio, TX
20-Bed Residential Treatment Center for Adolescent Females

Position Summary

Nexus Neurorecovery Center - San Antonio is seeking an experienced and mission-driven Quality & Compliance Manager to lead regulatory compliance, quality improvement, staff training, and safety initiatives within our adolescent residential treatment program. This role drives the delivery of safe, effective, and compliant care by overseeing incident management, coordinating external audits, facilitating regulatory readiness, and supporting a culture of continuous improvement aligned with Texas HHSC and Joint Commission Behavioral Health standards.

What You'll Do

Quality Improvement & Risk Management
  • Analyze incident reports for trends, risk exposure, and improvement opportunities.
  • Lead root cause analyses for incidents, grievances, and sentinel events.
  • Chair the Quality Improvement Committee and drive QAPI initiatives.
  • Develop corrective action plans and track quality metrics aligned with state and Joint Commission standards.
Regulatory Compliance
  • Serve as the subject matter resource for Texas HHSC and Joint Commission Behavioral Health Accreditation standards.
  • Lead preparation for external surveys, audits, and accreditation visits.
  • Conduct internal compliance audits and ensure ongoing regulatory adherence.
Training, Education & Competencies
  • Organize the annual clinical skills fair for direct care and clinical teams.
  • Coordinate new hire orientation related to quality, safety, and compliance.
  • Manage competency tracking and support department-level evaluations.
  • Facilitate continuing education, in-service learning, and staff development.
Safety & Infection Prevention
  • Oversee safety initiatives, environmental rounds, and emergency drills.
  • Ensure infection prevention compliance with CDC and organizational protocols.
  • Lead investigations and reporting related to infection control breaches or outbreaks.
What We're Looking For

Education
  • Bachelor's degree in Nursing, Behavioral Health, Public Health, Healthcare Administration, or related field required.
  • Master's degree preferred.
Experience
  • Minimum 3 years of experience in healthcare or behavioral health quality, regulatory compliance, or patient safety.
  • Working knowledge of Texas HHSC licensing standards and Joint Commission Behavioral Health accreditation required.
Licensure/Certification
  • CPHQ, CIC, or related quality/infection prevention certifications preferred.
Skills & Competencies
  • Strong analytical, investigation, and documentation ability.
  • Excellent communication and facilitation skills for training and committees.
  • Ability to collaborate across disciplines and lead improvement initiatives.
  • Proficient in Microsoft Office and quality management software.

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