Y-Team Director

Position Summary

The Y-Team Director is a corporate-level quality and compliance professional responsible for evaluating, validating, and strengthening regulatory compliance across the organization’s behavioral health facilities. Reporting to the Corporate Quality Director, this position plays a key role in survey readiness, regulatory compliance, performance improvement, and the ongoing validation of corrective actions.

This is a highly visible, hands-on role that 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.

The Y-Team Director partners closely with facility leadership to identify compliance risks, evaluate operational and clinical processes, and ensure identified deficiencies are appropriately addressed and sustained.

Key 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.

Preferred Qualifications

• Education/Licensure: Current clinical licensure in the applicable state of practice is preferred.
• Experience: 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.

Knowledge, Skills & Abilities

The ideal candidate will demonstrate:

• 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.

Travel & Working Conditions

This position requires regular travel between company facilities. Travel frequency will be based on organizational needs, scheduled audits, survey readiness activities, identified compliance concerns, and Plan of Correction follow-up.

The Y-Team Director works in both office and inpatient behavioral healthcare environments and may enter patient care areas while conducting audits and surveys. The position is not routinely responsible for providing direct patient care; however, the employee must follow all applicable facility safety, infection prevention, confidentiality, HIPAA, and security requirements while on-site.

This role requires regular travel between hospital locations, with an expectation of being onsite approximately four days per week.

The position requires the ability to sit, stand, and walk for extended periods; utilize a computer; review electronic and paper medical records; communicate effectively with employees and leadership; and perform other physical activities necessary to conduct facility surveys and compliance reviews.

The employee must maintain all required health documentation, including tuberculosis screening/testing and other documentation required by organizational policy or applicable regulatory requirements.

Freedom provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or any other characteristic protected by federal, state or local laws.  This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.