Assistant Director Transplant Quality and Regulatory

Montefiore Health System•North Charleston, SC

5d•$138,400 - $173,000•Onsite

About The Position

The Assistant Director of Transplant Quality & Regulatory is a subject matter expert responsible for directing and overseeing transplant quality, regulatory compliance, patient safety, and data management activities across the solid organ transplant programs. This role works collaboratively with physician, clinical, operational, and administrative leadership, as well as with Risk Management, Compliance, Information Technology, and Quality & Safety departments, to support regulatory readiness, performance improvement, and high-quality patient-centered care throughout the transplant continuum. The Assistant Director oversees a comprehensive transplant quality and compliance program focused on adherence to all applicable regulatory and accreditation requirements, including those established by the Organ Procurement and Transplantation Network / United Network for Organ Sharing, Centers for Medicare & Medicaid Services, Scientific Registry of Transplant Recipients, and The Joint Commission. This includes oversight of quality assessment and performance improvement (QAPI) activities, patient safety initiatives, clinical performance metrics, regulatory audits and inspections, adverse event review, corrective action planning, and continuous process improvement initiatives. This role provides strategic oversight and operational leadership for the transplant data management team, ensuring accurate and timely regulatory reporting, data integrity, dashboard development, analytics, and integration of transplant-related data across internal and external reporting systems including Epic Systems, Phoenix, UNOS, and SRTR platforms. The Assistant Director serves as a key resource to transplant leadership and is authorized to access all transplant program functions, records, and operational areas relevant to quality, compliance, and patient safety activities under review. The position serves as a key driver in advancing a culture of regulatory excellence, accountability, innovation, interdisciplinary collaboration, and continuous quality improvement to support optimal patient outcomes and organizational performance.

Requirements

Masters degree required.
4-6 years Nursing experience required.
4-6 years Transplant experience required.
New York State Registered Professional License and current registration or valid permit to practice in New York State required.
Proficient Leadership Skills And Ability To Effectively Communicate With Various Stakeholders, Including Transplant Surgeons, Nurses, And Administrative Staff.
Proficient in word, excel, and power point.
Excellent written and oral communication; proficient editing skills and detail orientation.

Responsibilities

Oversee and monitor all aspects of the transplant quality and compliance program, including policies, procedures, and protocols.
Develop and implement a comprehensive transplant quality and compliance program in accordance with regulatory standards and guidelines.
Establish and implement written policies to identify report, analyze, and address transplant-related adverse events. Actively participates in Quality Review processes, Root Cause Analysis, case debriefings, and medical staff Morbidity & Mortality (M&M) meetings to assess situations to identify potential improvements and respond to grievances, patient complaints, regulatory inquiries.
Conduct regular audits and reviews to ensure compliance with regulatory standards and identify areas for improvement.
Collaborate with medical staff, administrators, and other stakeholders to develop and implement quality improvement initiatives.
Facilitates solid organ transplant specific quality and P&P meeting structure, including but not limited to: scheduling, coordinating, developing agendas with the program directors, taking minutes as needed, distributing documents, preparing and presenting presentations, & ensuring accuracy and timeliness of information.
Utilizes tools to track the following: Performance Improvement activities and CAPs, Adverse Events, Transplant Dashboards (Operational and Clinical outcomes), Patient Complaints, Policy Stat.
Work together with Data team to keep tools up to date and to assess for accuracy.
Responsible for accurate and timely submission of data to UNOS (TIEDI forms), Renal Network, and the timely review of data in the SRTR. Audit the integrity of data entered by the transplant teams to ensure regulatory compliance within our EMR EPIC of the Transplant Coordinators.
Retrieves and integrates transplant data with numerous internal and external systems, EMR/Phoenix, SRTS, UNOS for transplant leadership team and physician providers.
Subject matter expert (SME) of EPIC Phoenix; work closely with the EPIC team, OR team, and the Phoenix team to assure all regulatory data is captured within the system.
Provide leadership and direction to the transplant data management team, including hiring, training, and performance evaluations.
Develop and maintain relationships with regulatory agencies and participate in audits and inspections.
Stay up-to-date on industry best practices and changes in regulatory standards related to transplant quality and compliance.
Communicate and collaborate with other departments and teams within the medical center to promote a culture of quality and compliance.
Serve as a resource and subject matter expert on transplant quality and compliance for the medical center staff.
Prepare and present reports to senior leadership and stakeholders on the progress and outcomes of the transplant quality and compliance program.
Identify and address any compliance issues or concerns in a timely and effective manner.
Foster a culture of continuous improvement, innovation, and excellence within the transplant program.
Ensure the confidentiality and security of all patient information in accordance with HIPAA regulations.
Serve as a liaison between the medical center and external organizations, such as regulatory agencies, professional associations, and transplant networks.