Director of Quality Management Full Time

Director of Quality Management Full Time McAllen, Texas Facility Solara Specialty Hospital McAllen Req ID 549604 Post Date 11/13/2025 Category Compliance DescriptionAt ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.Job SummaryResponsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Body. Facilitates performance improvement activities, and CQI activities throughout the hospital. Acts as resource person to administrative team, department manager’s, and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, such as, JCAHO, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the hospital. Acts as the Facility Ethics & Compliance Officer.Essential FunctionsResponsible for planning and implementing the performance improvement program to meet the needs of the hospitalFacilitates performance improvement and CQI activities throughout the hospital through effective organizational skills and ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team, and Governing Body to facilitate the hospital-wide Performance Improvement programMaintains awareness of changes in the regulations and requirements by accrediting bodies and current methodology and practicesManages and operates equipment safely and correctlyCommunicates appropriately and clearly to physicians, staff, CCO and administrative teamUses database systems to document occurrences, medical staff review functions, committee review and actionsCompiles reports for committees and administrative teamOversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulationsMaintains a good working relationship both within the department and with other departmentsConsults with other departments as appropriate to collaborate in patient care and performance improvement activitiesParticipates in risk management and safety activitiesProvides support and assistance to medical staff officers, committee chairpersons and Governing Body, as requiredServes as the primary liaison to the Regional Compliance Director, acting as the main point of contact for workforce members with compliance-related questions or concernsEscalates compliance issues promptly to the Regional Compliance Director for review and guidanceMeets regularly with the Regional Compliance Director to discuss compliance concerns, trends, and areas for improvementPrepares and submits quarterly compliance reports to facility leadership and the Regional Compliance Director for awareness, findings, and potential trends in the facilityKnowledge/Skills/Abilities/ExpectationsExcellent oral and written communication and interpersonal skillsBasic computer skills with working knowledge of Microsoft Office, word-processing and spreadsheet softwareKnowledge of current state, federal and local laws and regulations governing employee healthcare needsKnowledge of accreditation standards and compliance requirementsAbility to demonstrate critical thinking, appropriate prioritization and time management skillsAbility to work under stress and to respond quickly in emergency situationsAbility to spend a limited amount of time on travel requiredMust have good and regular attendanceMust read, write and speak fluent EnglishPerforms other related duties as assignedQualificationsEducationDegree in a healthcare related field, degree in nursing is preferredLicenses/CertificationsLicensed as a Registered Nurse in the state preferredCertified Professional Healthcare Quality (CPHQ) certification preferredExperienceMinimum three years’ experience in Quality and/or Risk Management in a hospital setting