Job Description

Posting number: 2026-06060

Department: Dept. of Social and Health Services

Division: BHHA

Job classification: WMS BAND 2

Posting type: Open & Promotional

Categories: Administration, Mental Health, Public Health

DSHS BHHA Civil Center Director of Certification and Accreditation

The Behavioral Health & Habilitation Administration (BHHA) is responsible for delivering high-quality inpatient psychiatric treatment to individuals served at Western State Hospital (WSH). Within BHHA, the Director of Certification and Accreditation reports directly to the Chief Quality Officer and is responsible for civil center certification, accreditation, and continuous survey readiness.

In this role, you will partner with hospital leadership, clinical disciplines, quality teams, external accrediting bodies, and statewide stakeholders. You will support the hospital’s efforts to meet and sustain compliance with CMS Conditions of Participation (CoPs), Joint Commission standards, RCW, WAC, and other regulatory requirements. You will lead the development, implementation, and monitoring of quality improvement systems that strengthen patient care, safety, and operational excellence.

This is an opportunity to lead transformational change in a complex psychiatric hospital environment. The successful applicant will improve survey readiness, build strong collaborative relationships, and leave a lasting impact on the hospital’s ability to maintain certification and deliver safe, high-quality care.

This role offers meaningful executive leadership experience, collaboration with multidisciplinary teams, and the opportunity to influence statewide psychiatric hospital practices within BHHA.

Telework is available up to two days per week for this role. Pierce County employees are eligible to receive an Orca Card for transportation needs.

Some of what you’ll do:

• Coordinate, direct, and oversee all civil center certification and accreditation activities, ensuring continuous readiness for CMS and other accrediting bodies.
• Lead the Quality Assessment and Performance Improvement (QAPI) program, including development, implementation, and monitoring of quality improvement initiatives.
• Manage survey readiness activities, including mock surveys, tracer activities, documentation preparation, and corrective action plan development.
• Provide subject matter expertise on CMS CoPs, Joint Commission standards, RCW, WAC, and other regulatory requirements.
• Oversee hospital-wide auditing processes to evaluate compliance, identify gaps, and develop action plans.
• Elevate compliance concerns to executive leadership and coordinate timely resolution.
• Facilitate workgroups, committees, and leadership councils related to quality, safety, and standards.
• Build strong collaborative relationships with internal and external stakeholders to support quality improvement and survey readiness.
• Provide oversight of the Quality Improvement Unit, including supervision, performance management, and staff development.
• Coordinate survey activities with DOH, CMS, and other accrediting bodies, including complaint, monitoring, follow-up, and unannounced surveys.
• Support the Chief Quality Officer in their absence and participate in hospital-wide emergency management responsibilities.
• Analyze data and monitor quality metrics across departments to ensure compliance and drive improvement.
• Ensure QAPI standards are reflected across wards, centers, and departments.
• Develop strategic plans for long-range compliance with CMS and accreditation standards.

What we’re looking for:

Professionals with a bachelor’s degree in Business Administration, Nursing, Public Health, Health Administration, or a closely allied field and five years of experience with certification, accreditation, and regulatory survey processes in a CMS-certified or Joint Commission-accredited facility or psychiatric hospital.

Required skills and experience include:

• Three years of supervisory experience.
• Three years managing complex projects from planning through evaluation.
• Two years of experience in quality assurance and improvement.
• Demonstrated facilitation skills.
• Ability to work effectively with community agencies and advocacy groups.

Preferred qualifications:

• Master’s degree in Business Administration, Nursing, Public Health, Health Administration, or a closely allied field.
• Knowledge of RCW, WAC, Medicaid State Plan, HIPAA, and psychiatric hospital regulatory requirements.
• Executive-level experience in a CMS-certified or Joint Commission-accredited psychiatric hospital.

Why a person would want this job:

This role offers the opportunity to work directly with executive leadership in a position of significant influence. You will shape hospital-wide quality systems, strengthen compliance, and directly impact patient care and safety. The work is meaningful, fast-paced, and provides deep insight into every department and program within the hospital.

What a person learns, does, and becomes:

You will gain a comprehensive understanding of hospital operations from a quality perspective, develop advanced leadership skills, and build expertise in regulatory compliance, accreditation, and performance improvement.

What you need to do to be successful:

Create a collaborative environment that engages internal and external stakeholders in assessing and improving quality. Build strong relationships, manage competing priorities, and maintain continuous readiness for surveys.

Questions?

Email Jourdan Kovacs at jourdan.kovacs@dshs.wa.gov, reference 06060. Learn more about DSHS at www.dshs.wa.gov

The Department of Social and Health Services’ (DSHS) vision that people find human services to shape their own lives requires that we come together with a sense of belonging, common purpose, shared values, and meaningful work. It is crucial to our agency’s vision that you bring a fairness, access, and social justice commitment to your work with DSHS. We strive to support all Washingtonians, including Black, Indigenous, and People of Color, people with physical, behavioral health, and intellectual disabilities, elders, LGBTQIA+ individuals, immigrants and refugees, and families building financial security.

Supplemental information

Prior to a new hire, a background check including criminal record history may be conducted. Information from the background check will not necessarily preclude employment but will be considered in determining the applicant's suitability and competence to perform in the job. This announcement may be used to fill multiple vacancies. Employees driving on state business must have a valid driver's license. Employees driving a privately owned vehicle on state business must have liability insurance on the privately owned vehicle.

Washington State Department of Social and Health Services is an equal opportunity employer and does not discriminate in any area of employment, its programs or services on the basis of age, sex, sexual orientation, gender, gender identity/expression, marital status, race, creed, color, national origin, religion or beliefs, political affiliation, military status, honorably discharged veteran, Vietnam Era, recently separated or other protect­ed veteran status, the presence of any sensory, mental, physical disability or the use of a trained dog guide or service animal by a person with a disability, equal pay or genetic information. Persons requiring accommodation in the application process or this job announcement in an alternative format may contact the Recruiter at (360) 725-5810. Applicants who are deaf or hard of hearing may call through Washington Relay Service by dialing 7-1-1 or 1-800-833-6384.

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