Director of Quality Management

Kindred Hospitals; San Antonio (TX); On-site; USD 90,000 - 130,000; Full time

Job summary

Kindred Hospital San Antonio Central is seeking a leader to plan and drive the hospital-wide performance improvement program, provide education to medical staff and hospital leadership, and lead risk management efforts.

You will collaborate with clinical leaders, department managers, and Governing Body to ensure regulatory readiness, quality reporting, and alignment with accreditation standards, acting as the Ethics & Compliance liaison as needed.

Qualifications

• Bachelor’s degree in a healthcare-related field required.
• 3+ years of experience in Quality and/or Risk Management in a hospital setting.
• RN licensure and CPHQ preferred.
• Knowledge of federal, state, and local healthcare regulations.

Responsibilities

• Plan, implement, and oversee hospital-wide performance improvement program.
• Facilitate CQI activities with clinical leadership and Governing Body.
• Maintain awareness of regulatory changes and ensure accreditation alignment.
• Oversee preparation for regulatory surveys and audits; educate departments.
• Use database systems to document occurrences, staff reviews, and committee actions.
• Communicate with physicians, staff, and leadership on quality initiatives.
• Collaborate across departments to improve patient care and performance.
• Participate in risk management and patient safety activities.

Skills

Communication skills

Computer skills

Regulatory & compliance knowledge

Accreditation & QA methodologies

Critical thinking & time management

Travel flexibility

Stress management

Education

Bachelor’s degree in healthcare or related field

Bachelor’s degree in Nursing (preferred)

Job description

Description

Kindred Hospital San Antonio Central, is located inside Baptist Medical Center is a long-term acute care (LTAC) hospital specializing in the treatment of patients recovering from post-intensive care and medically complex conditions. Our hospital provides both intensive care and telemetry-level services, offering advanced monitoring and support for patients requiring extended medical care. With a multidisciplinary team dedicated to personalized treatment plans, we focus on helping patients achieve significant recovery and transition to the next level of care.

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.

Qualifications

Education

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

• 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)

• 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)