Director Quality Management & Compliance

About the role

Cody Regional Health is seeking an experienced healthcare leader to join our team as Director of Quality Management & Compliance. This is a key organizational leadership role with responsibility for integrating and advancing Quality Management, Performance Improvement, Risk Management, Patient Safety, Infection Prevention & Control, Regulatory Survey Readiness, Case Management, Utilization Review, and Corporate Compliance across our healthcare system. The Director works closely with Senior Leadership, the Board of Trustees, Medical Staff, and clinical and administrative leaders to promote safe, effective, patient-centered care while ensuring compliance with federal, state, accreditation, and other regulatory requirements.

What You’ll Do

• Provide strategic leadership for organizational quality, patient safety, risk management, infection prevention, and performance improvement programs.
• Lead regulatory and accreditation survey readiness, preparation, coordination, and corrective action efforts.
• Oversee Case Management and Utilization Review functions for the hospital.
• Direct and maintain the organization’s Compliance Program and Code of Conduct.
• Serve as a trusted and independent resource for compliance concerns, investigations, and resolution.
• Analyze quality and performance data to identify trends, opportunities, and strategies for improvement.
• Partner with clinical and administrative leaders to develop and implement policies, processes, and improvement initiatives.
• Provide meaningful reporting and recommendations to Senior Leadership, the Board of Trustees, and applicable regulatory bodies.
• Develop education and training related to quality, patient safety, regulatory compliance, and organizational expectations.
• Foster a culture of integrity, accountability, collaboration, patient safety, and continuous improvement.

What We’re Looking For

• Registered Nurse with a BSN or bachelor’s degree in a related field required; master’s degree preferred.
• Minimum of five years of professional healthcare experience, preferably including experience in an acute-care setting and/or healthcare compliance.
• Working knowledge of healthcare quality, performance improvement, regulatory requirements, and survey processes.
• Quality leadership experience strongly preferred, including previous Quality Director experience.
• Strong understanding of healthcare regulatory and compliance requirements.
• Demonstrated leadership, analytical, communication, presentation, and policy-development skills.
• Ability to work effectively with executive leadership, governing boards, medical staff, clinical leaders, and employees throughout the organization.

Certifications

• Certified Professional in Healthcare Quality (CPHQ) required within one year of hire.
• A nationally recognized healthcare compliance certification such as CHC, CHRC, CHPC, or a comparable credential with transferable competencies, is required at hire or within two years of hire.
• Additional credentials or training such as CPPS, CPHRM, IHI, TeamSTEPPS, Lean, or Six Sigma are preferred.

Work Location

Cody, Wyoming — Onsite Only