Director of Quality, Ethics, and Compliance

About the role

The Director of Quality, Ethics, and Compliance plays a crucial role in ensuring the hospital adheres to regulatory standards and provides high-quality care. They are responsible for planning and implementing the performance improvement program, facilitating performance improvement and continuous quality improvement activities, and overseeing regulatory surveys.

Responsibilities

• Plans, implements, and oversees the hospital-wide performance improvement program to meet organizational goals.
• Facilitates performance improvement and CQI activities through collaboration with clinical leadership, department managers, ancillary services, the administrative team, and the Governing Body.
• Maintains awareness of regulatory changes and ensures alignment with current accreditation standards and best practices.
• Oversees preparation for regulatory surveys and audits; educates departments to ensure compliance with applicable requirements.
• Uses database systems to document occurrences, medical staff review activities, and committee actions, and prepares reports for leadership and committees.
• Communicates effectively with physicians, staff, CCO, and administrative leadership regarding quality and compliance initiatives.
• Collaborates across departments to support patient care improvement and organizational performance initiatives.
• Participates in risk management and patient safety activities.
• Provides support to medical staff officers, committee chairs, and the Governing Body as needed.
• Serves as primary liaison to the Regional Compliance Director and acts as the main point of contact for compliance-related questions or concerns.
• Escalates compliance issues appropriately and participates in regular compliance reviews and discussions.
• Prepares and submits quarterly compliance reports to facility leadership and the Regional Compliance Director.
• Ensures CMS, NHSN, and other quality reporting requirements are accurate, complete, and submitted timely.

Requirements

• Excellent oral and written communication and interpersonal skills.
• Basic computer skills with working knowledge of Microsoft Office and related systems.
• Knowledge of federal, state, and local healthcare regulations and compliance requirements.
• Understanding of accreditation standards and performance improvement methodologies.
• Strong critical thinking, prioritization, and time management skills.
• Ability to work under stress and respond effectively in urgent situations.
• Ability to travel as required.

Qualifications

• Bachelor’s Degree in a healthcare-related field (required).
• Bachelor’s Degree in Nursing (preferred).
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the state of practice, Upon Hire (preferred).
• CPHQ - Certified Professional in Healthcare Quality Upon Hire (preferred).
• 3+ years of experience in Quality and/or Risk Management in a hospital setting (required).

Skills

• Excellent oral and written communication and interpersonal skills.
• Basic computer skills with working knowledge of Microsoft Office and related systems.
• Knowledge of federal, state, and local healthcare regulations and compliance requirements.
• Understanding of accreditation standards and performance improvement methodologies.
• Strong critical thinking, prioritization, and time management skills.
• Ability to work under stress and respond effectively in urgent situations.
• Ability to travel as required.

Benefits

• Comprehensive benefits program including health, retirement, paid time off, work-life balance, and miscellaneous benefits.

Pay

Details about pay are not specified in the job posting.

Schedule

Details about the schedule are not specified in the job posting.