Quality & Compliance Director

This position is responsible for all quality, compliance, patient safety, and medical staff credentialing
activities within the hospital. It has primary responsibility for interfacing with the medical staff in matters
pertaining to the above, and for managing the relationship with the corporate departments responsible for
these functions at the system level.

Job Responsibilities

• Develops and implements strategy relating to matters of quality, outcomes and experience, and
for identifying and mitigating risks to the patient and/or staff. Creates and manages major
elements of the Strategic A3s relating to Right Care
• Oversees all activities relating to complying with the requirements for hospital accreditation and
licensure. Interfaces directly with JCAHO, the Mississippi Department of Health, and CMS as
necessary.
• Oversees the hospital's benchmarking programs. Is the hospital's point of contact and manages
the hospital's engagement with Leapfrog, Premier, Quest, and Vizient.
• Designs programs and oversees the orientation and education of staff in matters of quality,
regulatory compliance, patient safety, and patient experience.
• Is the primary liaison with the medical staff in matters of quality, regulatory compliance,
investigation of claims and actions, and patient experience. Is the hospital's representative to the
Peer Review, and Quality Committees.
• Assists the medical staff office in matters relating to credentialing, the delineation of privileges, the
medical staff bylaws and rules and regulations, and the disciplinary process.
• Is the primary interface with the corporate departments responsible for quality, compliance, and
patient safety at the system level.
• Participates in community health activities including mortality review, planning for events
impacting the health status of the citizenry, and in the adoption and administration of regulations
affecting the hospital.
• Prepares and oversees the budget for the assigned areas of responsibility. Recommends
programs and expenditures that can influence outcomes, experience, and/or the mitigation of risk.
• Develops and administers policy relating to quality, compliance, and patient safety.

Minimum Required

Five (5) years of clinical experience as a registered nurse or healthcare management with previous experience in Quality, Risk and/or Compliance.

Completion of a baccalaureate, associate or diploma degree in health-related field

Knowledge of licensure and accrediting requirements; ability to communicate and work effectively with medical staff, department heads and administration; excellent
organizational skills and problem-solving abilities.

Preferred/Desired

5 years' experience in quality, risk or compliance; baccalaureate, associate or diploma degree in a health-related field, nursing preferred; Certified Professional in Healthcare Quality (CPHQ)

Baccalaureate degree - Nursing preferred

Registered Nurse