About The Position

The Director of Performance Improvement/ Medical Staff Administrator is responsible for assisting the CEO in required tasks including, but not limited to conducting performance audits, monitoring quality and risk trends, policy and procedure development. NP and Medical staff scheduling, credentialing oversight and staff training. Oversee the collection as well as submission of all internally and externally submitted performance measures. Ensures that the facility compliance with The Joint Commission, CMS, AHCA, OSHA and other regulatory agencies standards. Responds quickly and proactively to performance indicators and data, resulting in higher quality staff and superior patient care. Audit records to ensure documentation is completed timely, effectively and according to facility policy, to ensure facility staff is following established policies and procedure Monitor quality and risk trends, policy and procedure development, staff training and ensure compliance with regulatory standards, contracts, licensing standards and guidelines. Prepare for, and conduct the monthly PI Committee, will create and implement action plans deriving from those meetings and regulatory surveys Coordinates Medical Staff and Nurse Practitioner schedules, administratively supervises NP coverage assignments

Requirements

  • Bachelor's Degree required
  • 3 to 5 years experience
  • Excellent communication (verbal and written) skills are essential
  • A strong knowledge of Joint Commission, CMS, OSHA and Patient Rights standards, and any other applicable federal and state laws and regulations governing mental health care facilities is required
  • Requires good computer skills
  • Analysis of data to improve performance, reduce risk, and provide safe and quality patient care
  • Able to work independently and collegially with all clinical disciplines
  • Must have good time management skills

Nice To Haves

  • Master's Preferred

Responsibilities

  • Conducting performance audits
  • Monitoring quality and risk trends
  • Policy and procedure development
  • NP and Medical staff scheduling
  • Credentialing oversight
  • Staff training
  • Oversee the collection as well as submission of all internally and externally submitted performance measures
  • Ensures that the facility compliance with The Joint Commission, CMS, AHCA, OSHA and other regulatory agencies standards
  • Responds quickly and proactively to performance indicators and data, resulting in higher quality staff and superior patient care
  • Audit records to ensure documentation is completed timely, effectively and according to facility policy, to ensure facility staff is following established policies and procedure
  • Monitor quality and risk trends, policy and procedure development, staff training and ensure compliance with regulatory standards, contracts, licensing standards and guidelines
  • Prepare for, and conduct the monthly PI Committee, will create and implement action plans deriving from those meetings and regulatory surveys
  • Coordinates Medical Staff and Nurse Practitioner schedules
  • Administratively supervises NP coverage assignments
© 2026 Teal Labs, Inc
Privacy PolicyTerms of Service