Director Quality Management PRN

ScionHealth•Muskogee, OK

About The Position

The Director Quality Management is responsible for planning and implementing the hospital’s performance improvement program and facilitating performance improvement and continuous quality improvement (CQI) activities throughout the hospital. The role provides education to medical staff, hospital staff, and the Governing Body and serves as a resource to the administrative team, department managers, and medical staff. The position performs clinical risk management functions, supports department managers in preparing for medical staff committees, and oversees preparation for regulatory surveys and audits, including The Joint Commission, state licensing reviews, and CMS validation surveys. The Director also serves as the Facility Ethics & Compliance Officer and primary liaison to the Regional Compliance Director. Responsibilities include supporting compliance reviews, escalating concerns, and preparing quarterly compliance reports. Cornerstone Specialty Hospitals provides acute care through physician-led teams for patients with complex conditions. Care may involve specialists in pulmonology, cardiology, infectious disease, and general surgery. Nurses in high-acuity units are certified in Advanced Cardiac Life Support, and respiratory therapists are available around the clock for patients with serious respiratory illnesses.

Requirements

Bachelor’s degree in a healthcare-related field.
At least 3 years of experience in Quality and/or Risk Management in a hospital setting.
Excellent oral and written communication and interpersonal skills.
Basic computer skills and working knowledge of Microsoft Office and related systems.
Knowledge of federal, state, and local healthcare regulations and compliance requirements.
Understanding of accreditation standards and performance improvement methodologies.
Strong critical-thinking, prioritization, and time-management skills.
Ability to work under stress and respond effectively in urgent situations.
Ability to travel as required.

Nice To Haves

Bachelor’s degree in Nursing.
RN (Registered Nurse) state licensure and/or compact state licensure in the state of practice, upon hire.
CPHQ (Certified Professional in Healthcare Quality), upon hire.

Responsibilities

Plan, implement, and oversee the hospital-wide performance improvement program to meet organizational goals.
Facilitate performance improvement and CQI activities in collaboration with clinical leadership, department managers, ancillary services, the administrative team, and the Governing Body.
Maintain awareness of regulatory changes and ensure alignment with current accreditation standards and best practices.
Oversee preparation for regulatory surveys and audits, and educate departments about applicable compliance requirements.
Use database systems to document occurrences, medical staff review activities, and committee actions; prepare reports for leadership and committees.
Communicate with physicians, staff, the CCO, and administrative leadership regarding quality and compliance initiatives.
Collaborate across departments to support patient care improvement and organizational performance initiatives.
Participate in risk management and patient safety activities.
Support medical staff officers, committee chairs, and the Governing Body as needed.
Serve as the primary liaison to the Regional Compliance Director and the main contact for compliance-related questions or concerns.
Escalate compliance issues appropriately and participate in regular compliance reviews and discussions.
Prepare and submit quarterly compliance reports to facility leadership and the Regional Compliance Director.
Ensure CMS, NHSN, and other quality reporting requirements are accurate, complete, and submitted on time.
Perform clinical risk management functions and assist department managers with preparation for medical staff committees.
Serve as the Facility Ethics & Compliance Officer.