Director of Quality, Ethics, and Compliance Licensed or Non-licensed

Kindred; Rahway (NJ); On-site; USD 93,000 - 118,000; Full time

Job summary

Kindred Hospital New Jersey - Rahway is seeking a leader to plan and implement the hospital-wide performance improvement program, educate staff, and drive CQI initiatives. This role serves as a resource to the administrative team and Governing Body, ensuring quality and compliance across the hospital.

The position requires 3+ years in quality or risk management in a hospital setting, and a Bachelor’s degree in a healthcare-related field (RN licensure preferred) with CPHQ certification preferred.

Qualifications

• Bachelor’s degree in healthcare-related field required.
• Nursing degree preferred.
• RN licensure in state or compact state (upon hire, preferred).
• CPHQ certification upon hire (preferred).
• 3+ years of experience in Quality and/or Risk Management in a hospital setting (required).

Responsibilities

• Plan, oversee hospital-wide performance improvement program to meet organizational goals.
• Facilitate CQI activities with clinical leadership and Governing Body.
• Maintain awareness of regulatory changes and align with accreditation standards.
• Prepare for regulatory surveys and educate departments for compliance.
• Document occurrences and committee actions; prepare reports for leadership.

Skills

Communication

MS Office

Regulatory knowledge

QI methodologies

Time management

Travel flexibility

Education

Bachelor’s degree in healthcare-related field

Bachelor’s degree in Nursing (preferred)

Job description

Description

Kindred Hospital New Jersey - Rahway is a 34-bed long-term acute care hospital located on the 4th floor within the RWJ University Hospital based in the medical district of Rahway, close to several educational institutions and Madison Avenue Park. We offer the same in depth care you would receive in a traditional hospital, but for an extended recovery period. We partner with your physician and offer 24-hour clinical care seven days a week so you can start your journey to wellness.

Job Summary

Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and the Governing Body. Facilitates performance improvement and continuous quality improvement (CQI) activities throughout the hospital. Acts as a resource to the administrative team, department managers, and medical staff. Performs clinical risk management functions and assists department managers with preparation for medical staff committees. Maintains oversight responsibility for all regulatory body surveys, including The Joint Commission (TJC), State Licensing Reviews, and CMS Validation surveys. Serves as the Facility Ethics & Compliance Officer.

Essential Functions

• Plans, implements, and oversees the hospital-wide performance improvement program to meet organizational goals.
• Facilitates performance improvement and CQI activities through collaboration with clinical leadership, department managers, ancillary services, the administrative team, and the Governing Body.
• Maintains awareness of regulatory changes and ensures alignment with current accreditation standards and best practices.
• Oversees preparation for regulatory surveys and audits; educates departments to ensure compliance with applicable requirements.
• Uses database systems to document occurrences, medical staff review activities, and committee actions, and prepares reports for leadership and committees.
• Communicates effectively with physicians, staff, CCO, and administrative leadership regarding quality and compliance initiatives.
• Collaborates across departments to support patient care improvement and organizational performance initiatives.
• Participates in risk management and patient safety activities.
• Provides support to medical staff officers, committee chairs, and the Governing Body as needed.
• Serves as primary liaison to the Regional Compliance Director and acts as the main point of contact for compliance-related questions or concerns.
• Escalates compliance issues appropriately and participates in regular compliance reviews and discussions.
• Prepares and submits quarterly compliance reports to facility leadership and the Regional Compliance Director.
• Ensures CMS, NHSN, and other quality reporting requirements are accurate, complete, and submitted timely.

Knowledge/Skills/Abilities/Expectations

• Excellent oral and written communication and interpersonal skills.
• Basic computer skills with 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.

Pay range: $93,267 - $118,289

ScionHealth has a comprehensive benefits package for benefit-eligible employees that includes Medical, Dental, Vision, 401(k), FSA/HSA, Life Insurance, Paid Time Off, and Wellness.

• Medical
• Dental
• Vision
• 401(k)
• FSA/HSA
• Life Insurance
• Paid Time Off
• Wellness

Qualifications

Education

• Bachelor’s Degree in a healthcare-related field (required) And
• Bachelor’s Degree in Nursing (preferred)

Licenses/Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the state of practice, Upon Hire (preferred) And
• CPHQ - Certified Professional in Healthcare Quality Upon Hire (preferred)

Experience

• 3+ years of experience in Quality and/or Risk Management in a hospital setting (required)