Director of Quality and Regulatory

Job Summary and Qualifications

This position supports the mission of Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children in optimizing the quality of life of all those served by expanding beyond the traditional focus on medical needs to the needs of the whole person. The Director of Quality is responsible to support the VP of Quality in advancing the organization’s quality improvement goals and for creating and maintaining a culture of continual regulatory readiness.

The Director of Quality will oversee hospital compliance as it pertains to regulatory and public reporting requirements, including but not limited to The Joint Commission, Center for Medicare and Medicaid Services, and Colorado Department of Public Health and Environment. Manages Quality programs and regulatory functions. Accountable for ongoing continuous survey readiness, mock surveys facilitation, regulatory rounding throughout the hospital, survey coordination, post survey follow up, and regulatory compliance with licensing and accreditation. Oversees the completion of various regulatory and quality survey submission requests. Interacts with senior management, multidisciplinary departments, and the medical staff as required to keep all adequately informed and educated on quality and regulatory issues. Assists in the management of policies and procedures. Participates in process improvement and change management initiatives related to quality, regulatory, and patient safety initiatives and goals.

This role will also be active in patient care areas, observing practices, reviewing medical records and collaborating with management, front line staff and the medical staff when there are opportunities to improve the organization’s compliance. Provides day to day personnel management of Quality Coordinator team. When need arises, performs other duties as assigned by supervisor.

Position Requirements

• Licensure/Certification/Registration: CPHQ or other Quality Certification highly desirable.
• Education: Baccalaureate and graduate degree in a healthcare related field or management program required.
• Experience: Minimum of three years progressive experience in healthcare quality management, including demonstrated management of individuals, teams, quality and regulatory compliance, i.e. TJC, CMS, and State Department of Health and Environment.
• Experience: Ability to analyze detailed reports, statistical data, and financial reports.
• Knowledge/Skills/Abilities: Ability to design and develop performance measures; Experience in providing data analysis, review, and action planning; Experience in providing education and presentations to varied groups of individuals, including executive and medical staff; Experience in core measure, complication and healthcare acquired condition review; Experience with policy and procedure development; Experience in facilitating PI teams using quality improvement methodology; Ability to effectively communicate both verbally and writing with hospital, medical staff and regulatory bodies; Proficient computer skills in Word, Excel, and Power Point.

Benefits

HCA HealthONE Presbyterian St. Luke's, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
• Free counseling services and resources for emotional, physical and financial wellbeing
• Totally Matched 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock
• Fertility and family building benefits with Progyny and adoption assistance.
• Referral services for child, elder and pet care, home and auto repair, event planning and more
• Consumer discounts through Abenity and Consumer Discounts
• Retailer partnerships
• Education assistance (tuition, student loan, certification support, dependent scholarships)
• Colleague recognition program
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.