Bachelor's Degree in a healthcare-related field is required.
Bachelor's Degree in Nursing is preferred.
Registered Nurse (RN) state licensure is preferred upon hire.
Certified Professional in Healthcare Quality (CPHQ) is preferred upon hire.
Three or more years of experience in Quality and/or Risk Management in a hospital setting is required.
Responsibilities
Plan, implement, and oversee the hospital-wide performance improvement program.
Facilitate performance improvement and continuous quality improvement initiatives across departments.
Collaborate with clinical leaders and administrative team to support quality initiatives.
Maintain knowledge of regulatory requirements and accreditation standards.
Oversee preparation for regulatory surveys and compliance reviews.
Educate department managers on compliant policies and procedures.
Utilize database systems for documenting occurrences and compiling reports.
Benefits
Opportunities for professional growth and development.
Supportive and team-oriented work environment.
Commitment to employee value and recognition.
Impactful role contributing to community well-being.
Involvement in continuous improvement and quality initiatives.
Full Job Description
Job Summary
Responsible for planning, implementing, and overseeing the hospital-wide performance improvement program to meet organizational and regulatory requirements. Provides education to medical staff, hospital staff, and the Governing Body while facilitating continuous quality improvement (CQI) activities across the organization.
Serves as a key resource to the administrative team, department managers, and medical staff, and performs clinical risk management functions. Maintains oversight of regulatory surveys and all performance improvement activities. Acts as the Facility Ethics & Compliance Officer, ensuring adherence to organizational policies, regulatory standards, and ethical practices.
Essential Functions
Plans, implements, and oversees the hospital-wide performance improvement program.
Facilitates performance improvement and CQI initiatives across all departments.
Collaborates with clinical leaders, department managers, administrative team, and Governing Body to support quality initiatives.
Maintains current knowledge of regulatory requirements, accreditation standards, and industry best practices.
Oversees preparation for regulatory surveys including Joint Commission, State Licensing, and CMS validation reviews.
Educates and supports department managers in maintaining compliant policies and procedures.
Utilizes database systems to document occurrences, track medical staff review activities, and compile reports for committees and leadership.
Participates in and supports risk management and patient safety initiatives.
Provides support to medical staff officers, committee chairpersons, and Governing Body as needed.
Serves as the Facility Ethics & Compliance Officer and primary liaison to the Regional Compliance Director.
Acts as the point of contact for workforce members regarding compliance-related questions and concerns.
Escalates compliance issues appropriately and participates in regular compliance reviews.
Prepares and submits quarterly compliance reports to facility and regional leadership.
Maintains effective working relationships across departments to support patient care and organizational goals.
Performs other duties as assigned.
Knowledge, Skills, and Abilities
Excellent verbal, written, and interpersonal communication skills.
Strong knowledge of accreditation standards, regulatory requirements, and healthcare compliance practices.
Demonstrated critical thinking, prioritization, and problem-solving abilities.
Ability to manage multiple initiatives in a fast-paced environment.
Proficiency in Microsoft Office applications, including Word and Excel.
Ability to work effectively under pressure and respond to urgent situations.
Knowledge of federal, state, and local healthcare regulations.
Ability to collaborate effectively with interdisciplinary teams.
Ability to travel occasionally as required.
Demonstrates reliability, professionalism, and regular attendance.
Ability to read, write, and speak fluent English.
Qualifications
Education
Bachelor's Degree in a healthcare-related field. (Required)
Bachelor's Degree in Nursing. (Preferred)
Licenses/Certifications
Registered Nurse (RN) - State Licensure and/or Compact State Licensure in the state of practice. (Preferred upon hire)
Certified Professional in Healthcare Quality (CPHQ). (Preferred upon hire)
Experience
Three (3) or more years of experience in Quality and/or Risk Management in a hospital setting. (Required)
About LifePoint Health
LifePoint Health is a healthcare company that owns and operates hospitals and other healthcare facilities across the United States. The company was founded in 1999 and is headquartered in Brentwood, Tennessee. LifePoint Health's hospitals offer a wide range of medical services, including emergency care, surgery, cardiology, oncology, and women's health. The company is committed to providing high-quality, compassionate care to all patients, regardless of their ability to pay. LifePoint Health is also dedicated to improving the health and well-being of the communities it serves through various community outreach programs and initiatives.
