RN Quality & Regulatory Compliance Director

1103 Team Member Services

United States

On-site

USD 100,000 - 187,000

Full time

14 days+

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Benefits offered by this job

Medical

Dental

Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off from Day One

403-B Retirement Plan

4 Weeks 100% Paid Parental Leave

Career Development

Whole Person Well-being Resources

Mental Health Resources and Support

Pet Benefits

Job summary

AdventHealth in Killeen, TX is seeking a Patient Safety/Quality and Regulatory Leader to coordinate committees, ensure regulatory compliance, and drive performance improvement across the organization.

The role requires a Bachelor's degree with healthcare quality or nursing background, strong data skills, and knowledge of Joint Commission/AHCA/CMS standards. Full-time day-shift position with competitive pay and comprehensive benefits.

Qualifications

Excellent verbal and written communication skills as demonstrated by application resume, work history, and interview process.
Ability to work independently or in a team environment.
Good math skills with an ability to understand and work with spreadsheets.
Ability to work with data that is of sensitive and confidential nature.
Skilled in use of computer programs such as Microsoft Excel, PowerPoint, and Word, Trove or similar Database.
Proficiency in database management and Electronic Medical Record navigation.
Working knowledge of or ability to learn and work with appropriate Joint Commission standards and AHCA/CMS regulations and information.
Good organizational skills, strong attention to detail, and ability and willingness to multitask.
Education in Performance Improvement such as Team Leader, Facilitator experience, Malcolm Baldrige, and/or LEAN Six Sigma.

Responsibilities

Facilitates ongoing and special committees/task forces, providing consultative support to clinical committees, PI teams, and other departments related to quality, regulatory concerns, and policies/procedures.
Serves as a resource for hospital departments regarding professional standards of practice and requirements of accreditation and regulatory agencies.
Coordinates and directs activities, tracers, and education to prepare the organization to meet the requirements of Joint Commission, AHCA, and CMS.
Communicates with courtesy and respect when interacting with internal or external customers, in person or on the telephone, maintaining a professional appearance and manner.
Coordinates the improvement work of teams, oversees the execution of improvement plans, assists teams in using improvement tools, and evaluates team leadership on progress.
Identifies deficient practice patterns, participates in Root Cause Analysis and FMEA teams, and provides recommendations for improvement and/or correction.
Serves as a resource on regulatory issues to leaders, facilitating the education of staff about changes in regulations that impact care delivery or other work practices.
If designated as the PSO Liaison, the incumbent will serve as the primary link between the assigned entity or entities, their affiliated providers, and one or more federally listed Patient Safety Organizations (PSOs), while ensuring compliance with the Patient Safety and Quality Improvement Act (PSQIA) by the assigned entity or entities and their staff.
The PSO Liaison will accurately define, implement, manage, and document all Patient Safety Evaluation System (PSES) processes in compliance with privacy, confidentiality, and security requirements established by organizational policies and federal regulations, while keeping leadership informed of PSES status and the level of engagement with the PSO(s) to improve patient safety and quality across the assigned entity or entities.