Director - Transplant Programs, Compliance and Quality - FT - Days - MRH

Memorial Healthcare

2d•Onsite

About The Position

The Director of Transplant Programs, Compliance and Quality oversees regulatory, compliance, quality, patient safety, and administrative operations for the Memorial Transplant Institute (MTI), including adult and pediatric solid organ transplant programs within Memorial Healthcare System. This role provides strategic and operational leadership for program development, regulatory readiness, quality performance, accreditation, and multidisciplinary coordination. It also establishes internal regulatory policies, monitors compliance with government standards, and ensures continuous survey readiness through audits, evaluations, and corrective actions. The Director leads quality improvement, patient safety, and operational effectiveness initiatives, while partnering with executive leadership to align transplant services with organizational strategic, financial, clinical, and regulatory goals.

Requirements

Bachelors (Required)
Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate, Registered Nurse License (RN LICENSE) - State of Florida (FL)
Requires critical thinking skills, decisive judgement and the ability to work with minimal supervision.
Must be able to work in a stressful environment and take appropriate action when required.
Ability to access, analyze and interpret various quality and regulatory databases (healthcare and transplant specific).
Bachelor's degree in Healthcare Administration, Business Administration, Nursing, or a related field.
A minimum of five (5) years of core work experience in a healthcare or clinical setting with progressive experience in transplant regulatory/quality, transplant medicine, and/or transplant clinical services, plus a minimum of three (3) years of leadership experience with proven track record of successfully managing complex quality and regulatory compliance initiatives required.

Nice To Haves

Master's degree preferred.
Transplant specific certifications preferred.

Responsibilities

Leads and mentors quality and compliance staff, promoting accountability, collaboration, and continuous improvement, while providing guidance on complex issues and overseeing data integrity in electronic documentation.
Oversees quality improvement initiatives, interdisciplinary teams, and performance reporting to ensure achievement of quality, safety, and regulatory objectives. Designs and implements quality management systems, monitors trends, and partners with clinical and executive leadership to address gaps and drive corrective actions.
Leads and oversees all regulatory surveys and audits for MTI. Provides onsite support for survey preparation and execution with regulatory, accreditation, and certification bodies including, but not limited to, Joint Commission (JC), Agency for Health Care Administration (AHCA), Centers for Medicare & Medicaid Services (CMS), the United Network for Organ Sharing (UNOS), the Organ Procurement and Transplantation Network (OPTN), and the Membership and Professional Standards Committee (MPSC) and conducts internal audits to identify and mitigate risks.
Collaborates with transplant and hospital leadership to support program integration, growth, and operational performance. Leads strategic planning, resource allocation, and program development initiatives to achieve organizational, financial, clinical, and patient experience goals.
Leads continuous regulatory readiness initiatives and ensures adherence to systemwide standards and policies, including tracer activities, mock surveys, gap analyses, and risk assessments. Communicates findings and recommendations to executive leadership.
Supports physician and leadership engagement across transplant programs while promoting a culture of accountability, collaboration, innovation, patient safety, and continuous improvement within the Memorial Transplant Institute.
Directs transplant education and training for clinical leadership and staff, fostering a culture of continuous compliance and survey readiness. Develops and delivers training on regulatory requirements, quality standards, and best practices, ensuring alignment with policies, evidence-based care, and documentation standards.
Prepares and presents reports to executive leadership on performance, compliance, and strategic priorities. Directs peer review, education, and safety initiatives to reinforce regulatory adherence and a culture of patient safety.
Provides administrative oversight and operational leadership for adult and pediatric solid organ transplant programs across Memorial Healthcare System, including heart, kidney, pancreas, and VAD/MCS services. Leads transplant governance activities, including committee oversight, multidisciplinary coordination, performance review, and executive reporting.
Serves as the primary liaison to regulatory and accrediting agencies and maintains strategic relationships with external partners, vendors, and professional organizations including, but not limited to, OPTN/UNOS, AST, TxAQM, NATCO, and ITNS, including coordination with OPO services.
Oversees administrative operations, including workflow optimization, standardization, and cross-functional coordination. Partners with finance, operations, nursing, and physician leadership to enhance access, capacity, efficiency, and service excellence while identifying risks and implementing improvement strategies.
Monitors regulatory, legal, reimbursement, and accreditation changes, as well as industry trends, and advises executive leadership accordingly. Develops and leads implementation plans to prioritize, communicate, and operationalize regulatory updates with clinical leaders and staff.
Oversees institute-wide clinical policies, procedures, and standard practices, including electronic policy management. Leads process improvement initiatives, evaluates adverse events, and maintains policies to strengthen compliance and operational efficiency. Ensures clinical documentation aligns with data reporting requirements.