Medical Clinical Quality & Compliance Analyst (Management Analyst III)

This position functions as the agency's nursing expert in internal auditing, risk management, serious incident oversight, human rights compliance, and system-wide quality improvement. This role encourages consistent, safe, and high-quality nursing and clinical practices across all CSB service areas by applying advanced nursing judgment to evaluate risks, interpret regulations, and propose corrective actions.

Conducts chart audits focused on nursing and medical documentation requirements, including medication administration, clinical assessments, care coordination, and DBHDS-required elements. Leads staff feedback meetings to review audit findings, clarify documentation expectations, and support performance improvement. These efforts ensure that corrective actions comply with DBHDS licensing requirements and DMAS Medicaid documentation mandates, promote sustainable compliance, and reinforce clinical accountability across programs.

Provides leadership in reviewing and evaluating serious incident reports related to nursing issues and offers ongoing support for general serious incident reporting reviews, ensuring accuracy, regulatory compliance, and the identification of medical or clinical contributing factors. Offers specialized support in developing, implementing, and monitoring corrective action plans resulting from audits, licensing findings, human rights investigations, serious incidents, and clinical quality-of-care concerns. Additionally, this role serves as the lead for human rights investigations involving nursing practices and supports other human rights investigations, ensuring trauma-informed investigative processes, adherence to 12VAC35-115 regulations, and appropriate follow-up to safeguard client rights and improve system integrity.

As an "ambassador of nursing quality," promotes strong partnerships between administrative and clinical teams, facilitates system-wide communication, and supports organizational change efforts. Collaborates with CSB medical leaders to develop, organize, and implement nursing-related CSB regulations, procedures, and compliance workflows; supports site-specific documentation needs; and ensures consistency across service areas. Provides leadership in developing, launching, and maintaining evidence-based nursing practices and regulatory compliance initiatives. The role helps foster a culture of high-quality care by developing nursing-specific training programs, supporting evidence-based practice adoption, strengthening the Nursing Community of Practice, and evaluating, designing, implementing, and sustaining clinical quality improvements.

Additional responsibilities include developing and maintaining nursing compliance guidance materials, supporting nursing site-specific procedures in collaboration with the CSB Director of Nursing Services, supporting integrated care initiatives, and contributing to the development of Field Guides and other clinical and regulatory tools. The incumbent also supports the agency's electronic compliance documentation system, including coverage rotation, to ensure consistent, accessible, and up-to-date regulatory information across the CSB.

The role demands the ability to work both independently and in team environments, utilizing strong clinical judgment, initiative, and autonomy. It eliminates obstacles to effective, high-quality nursing practice by clarifying expectations, fostering communication, enhancing staff competence, and leading evaluation and improvement processes aligned with compliance, human rights, and regulatory standards.

Key areas include:

• Medical record auditing and clinical documentation standards to ensure regulatory readiness
• Investigation and follow-up of human rights complaints
• Nursing practice, clinical risk management, and serious incident management
• Support for serious incident reviews, mortality assessments, and incident reporting
• Human Rights and DBHDS licensing compliance
• Development and implementation of corrective action plans and quality assurance programs related to nursing
• Compliance with DBHDS licensing and DMAS requirements
• Evidence-based nursing practice and training development
• Adherence to behavioral health and developmental disability standards
• Promote integrated care, implementation science, and process improvements
• Co-lead the Nursing Community of Practice and support system-wide training

(The illustrative duties listed in this specification are representative of the class but are not an all-inclusive list. A complete list of position duties and unique physical requirements can be found in the position description.)

• Independently designs, develops, and coordinates ongoing department programs and special projects;
• Performs a wide range of professional-level management work for more than one broad administrative function including complex analysis and diverse project management in a lead capacity;
• Coordinates and manages the work of administrative, para-professional, and/or professional-level staff in the day-to-day activities of selected projects. Plans, organizes, and coordinates changes to the policies, procedures, or processes related to multiple administrative functions (financial, procurement, budget, human resources, contract or grants administration, information technology systems, etc.);
• Plans and conducts or oversees studies or research activities to ensure program quality, determine unmet needs or ensure efficacy of existing programs;
• Provides guidance, recommendations, and advice to departmental managers;
• Serves on committees, task forces, and management teams to evaluate the effectiveness and efficiency of existing management/administrative systems;
• Writes, edits, and finalizes reports and presentations and presents findings and recommendations to department senior managers.

(The knowledge, skills and abilities listed in this specification are representative of the class but are not an-all inclusive list).

• Considerable knowledge of mission, goals, and objectives of the organizational unit, program, or activities to which incumbent is assigned;
• Considerable knowledge of the principles, practices, and techniques relating to the functional area of business operation (e.g. personnel, budgeting and financial management, contract administration and management);
• Knowledge of the principles, practices and techniques governing management, organization, operations and programmatic services;
• Ability to identify possible solutions for solving business problems;
• Ability to evaluate proposals and solutions in terms of benefits, costs, and overall impact on the project, program, or organization;
• Ability to make oral presentations to department management, other departments, or the public;
• Ability to write detailed, accurate reports, grants, or solicitations for pertinent areas of administration;
• Ability to use word processing and presentation software to prepare documents, and to use spreadsheet and statistical analysis software packages to store, manipulate, analyze and present data;
• Ability to supervise and train staff;
• Ability to lead assigned employees, including delegating and reviewing work assignments, providing coaching and guidance, monitoring and evaluating performance, and supporting training and development planning.

MINIMUM QUALIFICATIONS:
Any combination of education, experience, and training equivalent to the following:(Click on the aforementioned link to learn how Fairfax County interprets equivalencies for "Any combination, experience, and training equivalent to")
Graduation from an accredited four-year college or university with a bachelor's degree in field related to the assigned functional area; Plus four years of professional work experience with in the functional area.

CERTIFICATES AND LICENSES REQUIRED:
None.

NECESSARY SPECIAL REQUIREMENTS:
The appointee to this position will be required to complete a criminal background check, a Child Protective Services Registry check, and sanction screening to the satisfaction of the employer. Additional Work Schedule Requirements: 8:00am-4:30pm. May include evenings and weekends/holidays, on-call rotation.

PREFERRED QUALIFICATIONS:
Master's degree in nursing (MSN), public health (MPH), healthcare quality, healthcare administration, or a related field, along with at least five years of professional experience in behavioral health and/or developmental disability services. Experience should include knowledge of state and federal regulations, program evaluation, regulatory compliance, program licensing, corrective action planning, and billing requirements aligned with behavioral health and developmental disability regulations.

PHYSICAL REQUIREMENTS:
Ability to stand, stoop, bend, stretch, walk, climb, sit, type on a keyboard, and lift up to 15 pounds. Acuity of vision is required to read data on a computer monitor. Ability to use keyboard-driven equipment and communicate clearly with others. All duties performed with or without reasonable accommodations.

SELECTION PROCEDURE:
Panel Interview and may include a practical exercise.

Fairfax County Government prohibits discrimination on the basis of race, color, religion, national origin, sex, pregnancy, childbirth or related medical conditions, age, marital status, disability, sexual orientation, gender identity, genetics, political affiliation, or military status in the recruitment, selection, and hiring of its workforce.

Reasonable accommodations are available to persons with disabilities during application and/or interview processes per the Americans with Disabilities Act. TTY 703-222-7314. DHREmployment@fairfaxcounty.gov EEO/AA/TTY.
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