Regional Quality Manager

Provides quality, regulatory compliance, risk management, performance improvement, and staff education support across multiple assigned hospital facilities. Partners closely with Hospital Administrators, Directors of Nursing, facility Quality Managers, department leaders, medical staff, and other members of hospital leadership to ensure consistent implementation of organizational quality standards and regulatory requirements. This is a regional, facility-based position requiring frequent travel between assigned locations.

Responsibilities

• Provides oversight and support for Quality Assessment and Performance Improvement (QAPI) activities throughout assigned facilities.
• Reviews facility quality data, identifies trends and areas of concern, assists with the development of performance improvement initiatives, and monitors corrective actions to ensure improvements are implemented and sustained.
• Ensures QAPI activities are meaningful, measurable, properly documented, and aligned with organizational and regulatory expectations.
• Serves as a resource to facility leadership and provides guidance, education, and accountability related to quality management and performance improvement.
• Supports continuous regulatory compliance and survey readiness across all assigned facilities.
• Conducts facility audits, identifies compliance deficiencies, assists with corrective action plans and Plans of Correction (POCs), and monitors facilities to validate corrective actions.
• Assists assigned facilities with preparation for regulatory, licensing, accreditation, and validation surveys, including surveys conducted by CMS, state licensing agencies, and applicable accrediting organizations.
• May be required to travel to a facility on short notice in response to regulatory surveys, significant compliance concerns, or other operational needs.
• Assists with the identification, evaluation, monitoring, and mitigation of clinical and operational risks throughout assigned facilities.
• Reviews incidents and trends, supports investigations and root cause analyses, monitors corrective actions, and provides education designed to reduce risk and improve patient and employee safety.
• Collaborates with the Corporate Quality Director, facility administration, clinical leadership, and other appropriate parties regarding actual or potential risk situations.
• Identifies educational opportunities based on audits, regulatory findings, quality data, incidents, performance trends, and facility needs.
• Provides or coordinates education for hospital leadership and staff regarding quality standards, regulatory requirements, risk management, patient safety, documentation, policies and procedures, and performance improvement expectations.
• Ensures identified education and corrective training are completed, documented, and evaluated for effectiveness.
• Maintains regular communication with leadership at each assigned facility and provides hands-on support based on facility needs and organizational priorities.
• Conducts onsite reviews, evaluates compliance with established processes, assists leadership with resolving identified deficiencies, and communicates significant findings and recommendations to the Corporate Quality Director.
• Helps establish consistency and accountability across assigned facilities while recognizing facility-specific operational and regulatory needs.

Travel Requirements

Requires frequent and extensive travel to multiple hospital locations within the assigned region. Must be available to travel based on facility needs, scheduled audits, training, survey preparation, regulatory activity, and other quality or operational priorities. Travel may include multiple overnight stays per week, and the employee must maintain the flexibility necessary to adjust travel schedules based on the needs of assigned facilities. This position requires an active onsite presence and is not a remote or hybrid role.

Qualifications

• Strong knowledge of healthcare quality management, QAPI, regulatory compliance, risk management, performance improvement, and survey readiness.
• Excellent leadership, communication, organizational, analytical, and problem-solving skills.
• Ability to work independently and effectively with leadership teams across multiple facilities.
• Minimum 2 years of experience required.
• Hospital and/or behavioral healthcare experience is strongly preferred.
• Experience with CMS Conditions of Participation, state regulatory requirements, accreditation standards, Plans of Correction, QAPI, risk management, regulatory surveys, and clinical staff education is highly desirable.
• Ability to identify deficiencies, communicate expectations effectively, provide education and guidance, and hold facilities accountable for implementing and sustaining corrective actions.