Director of Quality Assurance

The Director of Quality Assurance & Compliance is responsible for overseeing all quality assurance, performance improvement, and compliance initiatives within the hospital. This role ensures that healthcare services meet regulatory standards, accreditation requirements, and internal quality benchmarks while optimizing patient safety and care outcomes. The director leads quality assurance programs, monitors hospital performance metrics, and ensures medical records are complete, accurate, and compliant with federal, state, and accrediting body regulations.

Key Responsibilities:

Quality Assurance & Performance Improvement (QAPI):

• Develop, implement, and oversee the hospital's Quality Assurance and Performance Improvement (QAPI) Program to enhance patient care.
• Conduct regular performance audits, medical record reviews, and clinical outcome evaluations to ensure compliance with best practices.
• Lead root cause analyses (RCA) for adverse events, near misses, and patient safety concerns, developing corrective action plans.
• Monitor and analyze key performance indicators (KPIs), such as patient satisfaction, readmission rates, infection control, and mortality/morbidity rates.
• Work with department leaders to implement evidence-based strategies to improve quality outcomes.

Regulatory Compliance & Accreditation:

• Ensure compliance with CMS, The Joint Commission, OSHA, HIPAA, and state health department regulations.
• Serve as the hospital's primary liaison during accreditation surveys, audits, and inspections.
• Maintain up-to-date knowledge of changing regulations and implement necessary hospital-wide adjustments.
• Develop and enforce hospital policies and procedures to ensure compliance with national standards.

Medical Records & Documentation Oversight:

• Ensure complete and accurate medical records that meet documentation requirements.
• Work closely with Health Information Management (HIM) and clinical staff to improve documentation practices and coding accuracy.
• Conduct chart audits to identify documentation gaps and provide feedback to providers.
• Implement Electronic Health Record (EHR) optimization strategies to enhance data integrity and compliance.

Leadership & Training:

• Provide education and training to medical, nursing, and administrative staff on quality improvement, compliance, and documentation best practices.
• Lead hospital-wide quality committees, presenting reports and recommendations to executive leadership.
• Collaborate with physicians, nurses, and department heads to promote a culture of continuous quality improvement (CQI).

Risk Management & Patient Safety:

• Identify and mitigate patient safety risks through proactive monitoring and intervention strategies.
• Investigate patient complaints, incidents, and sentinel events, recommending solutions to improve care delivery.
• Work with legal and risk management teams to reduce liability risks and ensure compliance with hospital policies.

Qualifications & Requirements:

Education & Experience:

• Minimum 3-7 years of experience in healthcare quality assurance, compliance, or risk management.
• Prior leadership experience in a hospital setting is highly preferred.
• Knowledge of healthcare accreditation processes, regulatory compliance, and performance improvement methodologies
• Experience with Electronic Health Records (EHR) and data analysis tools.

Skills & Competencies:

• Strong leadership and project management skills.
• Expert knowledge of healthcare regulations, accreditation standards, and quality improvement frameworks.
• Exceptional problem-solving, critical thinking, and analytical abilities.
• Excellent communication and interpersonal skills to collaborate across all hospital departments.
• Ability to interpret and analyze complex data to drive performance improvements.

Job Type: Full-time

Pay: $ $55.00 per hour

Benefits:

• Health insurance
• Paid time off

Application Question(s):

• Which regulatory agencies do you have experience with? (i.e. CMS)
• How many years of experience do you have in a quality assurance role at a hospital?
• Describe your experience managing quality assurance and leading performance improvement initiatives at a hospital.

Experience:

• Regulatory Compliance: 1 year (Required)

Work Location: In person