Job Opening in a 100+ bed hospital located in Southwestern North Carolina, for an experienced RN Director of Quality and Compliance to join their team.
The Director of Quality and Regulatory Compliance is responsible for ensuring that the facility remains in compliance with Joint Commission, state and federal standards; oversight responsibility for all regulatory body surveys, i.e., Joint Commission, State licensing Reviews, CMS Validation Surveys, health department, local regulatory reviews (fire marshal), and any other regulatory activity that may involve the facility. This responsibility includes staying current with Joint Commission, state, and local standards; educating facility staff about standards; and preparing the facility for such accreditation surveys.
Plans and coordinates quality and regulatory compliance activities to assure appropriate, high quality and regulatory compliant healthcare delivery. This includes development and implementation of hospital-wide Quality Assessment/Performance Improvement plans. Evaluation of effectiveness of corrective actions for identified problems and continuous quality improvement activities. Coordinates assessment of clinical practice patterns for purposes of medical staff credentialing and reappointment. Supervises staff responsible for coordinating a hospital-wide program aimed at compliance with Joint Commission core measure and Medicare quality initiatives.
The department has 5 FTE’s (which includes director and infection preventionist). This position will not be overseeing Risk and Pt Safety.
- Bachelor’s Degree required
- Master’s Degree preferred
- Basic Life Support
- Certification as a Professional in Healthcare Quality (CPHQ) through National Association for Healthcare Quality (NAHQ) or completion within two (2) years of hire.
- Must maintain certification throughout employment.
- Current, unrestricted RN license to practice in NC (NC licensure or multi-state [compact] license).
- Three years of leadership experience in acute hospital setting required.
- Two years’ experience leading quality/performance improvement and Joint Commission/CMS survey preparation and coordination required.
- Knowledge of medical staff oversight/credentialing preferred.
The Blue Ridge Mountains. The South Mountains. We’re home to Lake Lure, Chimney Rock and “small town friendly” cities such as Forest City, Rutherfordton, Spindale and more. Come relax and play in the Blue Ridge foothills of Western North Carolina. The town is currently home to more than 4,000 residents. It frequently receives recognition in national publications for its high quality of living stemming from excellent educational facilities, a quality public library, low crime and unemployment, and exceptionally fine medical facilities and personnel.
Competitive Salary Range!
Executive & Management Recruitment Services
(415) 770-1200 – call/text