Director of Quality & Regulatory Compliance

Concerto Renal Services•Lincolnwood, IL

5d•$115,000 - $140,000

About The Position

The Director of Quality and Regulatory Compliance provides strategic and operational leadership to ensure high-quality patient care, regulatory compliance, and continuous improvement across all Concerto dialysis facilities and service lines. This role reports to the Vice President of Quality and Regulatory Compliance and directs the quality and compliance agenda enterprise-wide, with accountability for meeting all CMS Conditions for Coverage, state licensure regulations, and internal standards. The Director serves as Concerto’s primary liaison with CMS, ESRD Networks, and SNF partners.

Requirements

RN license preferred but not required
Bachelor’s degree required; Master’s degree in healthcare administration, nursing, or related field preferred
Certification in Nephrology Nursing (CNN, CDN) or healthcare compliance preferred
7+ years of progressive dialysis leadership experience in quality, compliance, or operations
Demonstrated success leading survey readiness, compliance programs, and QAPI activities
Strong knowledge of CMS Conditions for Coverage, ESRD Networks, and state survey processes
Proven leadership, accountability, and ability to drive improvement across large organizations
Excellent communication and collaboration skills
Strong analytical, organizational, and project management skills

Responsibilities

Leads enterprise-wide quality and regulatory compliance programs in alignment with Concerto’s strategic objectives and regulatory requirements.
Oversees the development and execution of Concerto’s Clinical Quality Strategy (CQS), ensuring accurate and timely data collection, analysis, reporting, and action planning across key metrics.
Directs facility and regional teams in maintaining compliance with CMS Conditions of Coverage, state licensure, and all federal, state, and local regulations.
Serves as primary regulatory liaison with CMS, ESRD Networks, and state survey agencies. Coordinates survey readiness activities, directs mock surveys, and leads survey response planning.
Provides leadership and oversight of Quality Assessment and Performance Improvement (QAPI) activities enterprise-wide, ensuring goals are set, action plans developed, and progress monitored.
Analyzes KPI (Kt/V, Hgb, TSAT, Ferritin, AVF use, CVC >90 days, vaccination rates, bloodstream infections, etc.) and drives interventions to achieve enterprise targets.
Directs the preparation of enterprise-wide reports for executive leadership, Board of Directors, and regulatory agencies. Provides interpretation and recommendations for improvement.
Leads the development of policies, procedures, and protocols that support compliance and quality excellence.
Identifies high-risk areas and directs root cause analysis and corrective action planning. Tracks results and holds regional and facility leaders accountable for improvement.
Coordinates with Operations, Clinical, Medical Directors, Education, Dietitians, Social Work, and Biomedical Engineering to ensure integrated approaches to patient care and compliance.
Provides leadership, training, and mentorship to Regional Quality Managers, Regional Regulatory Compliance Managers, and Clinical Operations Nurses.
Collaborates with executive leadership to evaluate new business opportunities and expansion plans for compliance risks and requirements.
Ensures Concerto maintains a strong culture of safety, compliance, and accountability. Promotes hands-on leadership and field engagement.
Attends and co-leads regional QAPI meetings, ensuring regulatory and quality agendas are fully addressed.
Performs other related duties as assigned; responsibilities are not limited to the above.