Director Quality Ethics & Compliance

About the role

Kindred Hospital San Gabriel Valley is a 76-bed long-term acute care hospital offering the same in-depth care you would receive in a traditional hospital, but for an extended recovery period. We partner with your physician and offer 24-hour clinical care seven days a week so you can start your journey to wellness. We are located just over 2 miles outside of downtown West Covina, and right down the street from Covina Square Shopping Center.

Responsibilities

• Plan, implement, and oversee the hospital-wide performance improvement program to meet organizational goals.
• Facilitate performance improvement and continuous quality improvement (CQI) activities through collaboration with clinical leadership, department managers, ancillary services, the administrative team, and the Governing Body.
• Maintain awareness of regulatory changes and ensure alignment with current accreditation standards and best practices.
• Oversee preparation for regulatory surveys and audits; educate departments to ensure compliance with applicable requirements.
• Use database systems to document occurrences, medical staff review activities, and committee actions, and prepare reports for leadership and committees.
• Communicate effectively with physicians, staff, CCO, and administrative leadership regarding quality and compliance initiatives.
• Collaborate across departments to support patient care improvement and organizational performance initiatives.
• Participate in risk management and patient safety activities.
• Provide support to medical staff officers, committee chairs, and the Governing Body as needed.
• Serve as primary liaison to the Regional Compliance Director and act as the main point of contact for compliance-related questions or concerns.
• Escalate compliance issues appropriately and participate in regular compliance reviews and discussions.
• Prepare and submit quarterly compliance reports to facility leadership and the Regional Compliance Director.
• Ensure CMS, NHSN, and other quality reporting requirements are accurate, complete, and submitted timely.

Qualifications

• Bachelor's Degree in a healthcare-related field (required)
• Bachelor's Degree in Nursing (preferred)

Licenses & certifications

• 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)

Experience

• 3+ years of experience in Quality and/or Risk Management in a hospital setting (required)

Skills & abilities

• 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

Pay

$102K-124K

Benefits

ScionHealth has a comprehensive benefits package for benefit-eligible employees that includes Medical, Dental, Vision, 401(k), FSA/HSA, Life Insurance, Paid Time Off, and Wellness.