Market Director Quality, Ethics, and Compliance

Kindred Healthcare•Muskogee, OK

About The Position

The Market Director Quality, Ethics, and Compliance plans and implements the hospital’s performance improvement program, provides education to medical staff, hospital staff, and the Governing Body, and facilitates performance improvement and continuous quality improvement activities across the hospital. The role serves as a resource to the administrative team, department managers, and medical staff; performs clinical risk management functions; and supports department managers with medical staff committee preparation. The position oversees preparation for regulatory surveys and audits, including The Joint Commission, State Licensing Reviews, and CMS Validation surveys. It also serves as the Facility Ethics & Compliance Officer and primary liaison to the Regional Compliance Director. The director supports compliance reviews, escalates issues as appropriate, prepares quarterly compliance reports, and ensures required CMS, NHSN, and other quality reports are complete, accurate, and submitted on time.

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 requirements.
Use database systems to document occurrences, medical staff review activities, and committee actions, and prepare reports for leadership and committees.
Communicate with physicians, staff, the CCO, and administrative leadership about 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 primary liaison to the Regional Compliance Director and the main point of 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 timely.