Director Quality Ethics & Compliance

Kindred; Rancho Cucamonga (CA); On-site; USD 72,000 - 113,000; Full time

Benefits offered by this job

Medical benefits

401(k)

Wellness

Job summary

Kindred Hospital Rancho in Rancho Cucamonga, CA seeks a leader to plan and implement a hospital-wide performance improvement program. You will educate medical staff and governing bodies, drive CQI activities, and ensure regulatory readiness across surveys and audits.

The role serves as a resource to the administrative team and hospital departments, coordinating with the Regional Compliance Director to address compliance questions and reports.

Qualifications

• Excellent communication and interpersonal skills.
• Basic computer skills, MS Office proficiency.
• Knowledge of federal/state healthcare regulations and compliance requirements.
• Understanding of accreditation standards and CQI methodologies.
• Strong critical thinking, prioritization, and time management.

Responsibilities

• Plan, implement, and oversee hospital-wide performance improvement program.
• Educate medical staff and governance bodies; support committees.
• Oversee regulatory surveys and audits; ensure compliance.
• Document occurrences and prepare reports for leadership.
• Collaborate across departments to improve patient care and performance.
• Lead risk management and patient safety initiatives.
• Act as liaison to Regional Compliance Director and assist with compliance reviews.

Skills

Communication

MS Office

Regulatory knowledge

Accreditation standards

Critical thinking

Time management

Travel ability

Education

Bachelor's degree in healthcare-related field

RN degree (preferred)

Job description

Description

Kindred Hospital Rancho is a 55-bed long-term acute care hospital offering 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. For those who need special care, we offer an eight-bed ICU and three negative pressure rooms. We are located near downtown Rancho Cucamonga just off of Foothill Boulevard with close proximity to many shops and restaurants.

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) 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)

Pay Range

$52 - $82/Hr

Benefits

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