Northwest Integrated Health

24 Hour Referral Line 253-200-0300


Continuous Quality (Compliance) Improvement (CQI) Manager

Job description

Reports to Location
Office Manager Varies in Pierce County
FSLA Schedule
Full Time – Exempt M – F 8:00am-5:00pm
Will depend on experience

Job Summary:


The CQI responsibilities of this position include assisting in the preparation for federal, state and county audits and site reviews, participating in the development and maintenance of clinical and administrative forms and behavioral health documentation and compliance.


Supervises:                        CQI Staff

Primary Responsibilities:

  • Assist in the preparation for federal, state and county audits and site reviews; participate in internal audit/site review process and prepare responses to internal chart and encounter reviews completed by the system QA team.
  • Ensure completion of exit questionnaires and consumer satisfaction surveys. Compile results when requested and assist in analysis and action planning.
  • Participate on the system wide CQI Committee. Ensure that agenda items and any changes are implemented as required.
  • Work with all Clinical Supervisors to ensure that “real time” QA takes place with staff.
  • Participate in the development and maintenance of clinical and administrative forms, as well as instructions and standards for their completion.
  • Create and maintain electronic version of forms and train staff in their use.
  • Actively assist direct service staff accurately complete charting requirements and keep their charts updated. Create and maintain tracking lists for required elements and timelines, e.g., 90-day reviews, etc.
  • Review charts, training and documentation for completeness and quality utilizing structured protocols according to the WAC that meet state and federal requirements.
  • Provide technical assistance and training to individual staff about documentation requirements, charting, and policies and procedures by NWIH.
  • Work with other leadership staff to continuously improve documentation.
  • Facilitate peer reviews to take place regularly that focus on training and compliance.
  • During initial staffing care coordinators will review Admit Packet, Safety Crisis Plan, Intake, and ensure that the first goal around safety is initiated.
  • In subsequent staffing supervisors will focus on clinical best practices.
  • Coordinate with Operations Manager to complete audit requirements including but not limited to staff credentialing and appropriate documentation of training logs, performance evaluations, etc.
  • Coordinate with Operations Manager and data entry personnel to ensure the accuracy and integrity data submitted to funders, this includes, but is not limited to monthly reconciliation of duplications and overlapping data and outcome data. Oversee periodic encounter reviews to demonstrate integrity of data entry process.
  • Ensure that appropriate information and charts are prepared to support quality assurance outcomes through helpful reports to both leadership and staff.
  • Ensure that training is provided in new staff orientation on CQI related issues.
  • New staff training on charting expectations. Also, existing staff training in charting expectations.
  • Training all staff on CQI, Behavioral Health System and other changes or requirements.
  • Knowledge of applicable laws, contracts, administrative codes, and other regulations.
  • Knowledge of quality improvement theory, principles, and practice approaches.
  • Excellent interpersonal and organizational skills with the ability to communicate respectfully with families and professionals.
  • Investigation and reporting as required for critical incident.
  • Coordinate and conduct ongoing SUD chart audits and validate the accuracy of completed superbills against EHR documentation.
  • Promptly communicate the results of chart audits to the clinical supervisors as they are completed.
  • Identify critical issues/concerns and patterns of poor quality observed during chart audits and notify the Director of Behavioral Health.
  • Assess SUD staff talent and capabilities and communicate any issues or concerns to the appropriate clinical supervisor.
  • Develop and generate reports to meet agency standards.
  • Manage, develop and implement Quality Management policies and procedures for the organization.
  • Assist in developing SUD templates and workflows for EMR.
  • Other duties as assigned by the supervisor.

Education/Certification/License and Training Requirements:

  • Master’s in social work, psychology, behavioral sciences or equivalent. 
  • 5 years prior experience in compliance at state and federal levels.
  • Meet or exceed the requirements for Mental Health Professional (as defined by WAC 388-865).

Preferred experience:

  • Master’s in social work, psychology, behavioral sciences or equivalent.

Working Conditions:


Job is performed in an office clinic setting where you will be expected to use a computer, photocopier, fax machine, phone, and other miscellaneous equipment. The employee may be required to sit for extended periods of time at a desk or station, stand, walk, or kneel as part of their daily functions. Maybe asked to lift and/or move up to 30 pounds. The noise level in the work environment is moderate.

Travel Requirements: 


Travel between different NWIH facilities and to various meetings and conferences required.

Knowledge and Language Skills:


Must be able to read and interpret general business correspondence, policies, and procedures. Have the ability to write business letters, uncomplicated reports, instructions, and procedures. Ability to present information effectively and respond to questions from patients, staff, referral sources, and the general public. Should have basic knowledge of Microsoft Office and electronic medical records systems. Be able to prioritize workload and activities and follow through on assigned tasks to assure completion in a timely manner. Ability to handle multiple tasks and switch between tasks quickly. Able to establish and maintain effective working relationships with staff, clients, and outside contacts from a wide variety of ethnic, socioeconomic, and cultural backgrounds; good diplomatic skills including strong conflict-resolution skills.


Must be able to align with the Corporate Mission and Core Values:


Mission: To create a patient-centered, evidence-based, comprehensive, and integrated treatment model for substance-use-disorder; and to increase awareness about addiction as a chronic disease.

Core Values: Compassion, Integrity, Respect, Diversity, Excellence

General Requirements:

  • Complete tasks in a timely manner
  • Act professionally at all times.
  • Ensure work area is always clean and presentable.
  • Must be able to pass a criminal background check.
  • Must be authorized to work in the United States.
  • Proof of negative TB test within past 12 months or ability or test within first six months of employment.