Market Director Quality, Ethics, and Compliance

ScionHealth•Muskogee, OK

About The Position

The Market Director Quality, Ethics, and Compliance plans and implements the hospital’s performance improvement program, facilitates performance improvement and continuous quality improvement activities, and supports quality, patient safety, and risk management across the hospital. The role provides education and acts as a resource for medical staff, hospital staff, the Governing Body, the administrative team, and department managers. The position oversees preparation for regulatory surveys and audits, including The Joint Commission, state licensing reviews, and CMS validation surveys. It monitors regulatory changes and helps ensure alignment with accreditation standards and best practices. The role also uses database systems to document occurrences, medical staff review activities, and committee actions, and prepares reports for leadership and committees. As the Facility Ethics & Compliance Officer, the position serves as the primary liaison to the Regional Compliance Director and the main contact for compliance questions or concerns. It escalates compliance issues, participates in regular compliance reviews, and submits quarterly compliance reports to facility leadership and the Regional Compliance Director. The role also ensures CMS, NHSN, and other quality reports are accurate, complete, and submitted on time.

Requirements

Bachelor’s degree in a healthcare-related field (required).
At least 3 years of experience in Quality and/or Risk Management in a hospital setting (required).
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 (preferred).
RN - Registered Nurse state licensure and/or compact state licensure in the state of practice, upon hire (preferred).
CPHQ - Certified Professional in Healthcare Quality, upon hire (preferred).

Responsibilities

Plan, implement, and oversee the hospital-wide performance improvement program to meet organizational goals.
Facilitate performance improvement and continuous quality improvement activities in collaboration with clinical leadership, department managers, ancillary services, the administrative team, and the Governing Body.
Monitor regulatory changes and ensure alignment with current accreditation standards and best practices.
Oversee preparation for regulatory surveys and audits, and educate departments on applicable requirements.
Use database systems to document occurrences, medical staff review activities, and committee actions; prepare reports for leadership and committees.
Communicate quality and compliance initiatives to physicians, staff, the CCO, and administrative leadership.
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 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 on time.
Perform clinical risk management functions and assist department managers with preparation for medical staff committees.