Director of Quality, Risk Management, and Com

POSITION SUMMARY

The Director of Quality, Risk Management, and Compliance (DQRC) provides strategic and operational leadership for the organization's quality improvement, patient safety, risk management, regulatory compliance, credentialing, and privileging programs. The DQRC develops, implements, monitors, and improves systems that promote high-quality, safe, equitable, and compliant care while identifying and mitigating clinical and operational risk.

The DQRC ensures alignment with applicable federal and state regulations and HRSA, FTCA, NCQA, CMS, payer, accreditation, and organizational requirements. The position provides leadership for quality assurance and performance improvement, risk assessments and incident management, compliance, credentialing and privileging, clinical policies, audits and monitoring, and organizational reporting.

The DQRC collaborates with Executive and Clinical Leadership, Medical and Dental Leadership, Operations, Human Resources, Information Technology, Health Information Management, Provider Enrollment, and other departments. The position serves as a subject matter expert and advisor to leadership and governance bodies on quality, risk, compliance, provider competency, credentialing, privileging, and patient safety.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Quality Improvement

• Provide strategic leadership for the organization's Quality Improvement/Quality Assurance program and continuous improvement framework.
• Establish measurable quality goals, performance indicators, improvement priorities, and sustainability strategies aligned with organizational priorities.
• Monitor clinical quality measures, patient outcomes, operational performance, utilization, and other key indicators to identify trends and improvement opportunities.
• Lead Quality Improvement projects, including project charters, interventions, action plans, timelines, performance measures, and sustainability plans.
• Evaluate the effectiveness of corrective and improvement actions.
• Lead or oversee audits, monitoring, and performance assessments addressing organizational policies, regulatory requirements, and evidence-based practices.
• Partner with Clinical Leadership to address quality and patient safety gaps and support data-driven decision-making.
• Ensure quality activities support HRSA, FTCA, NCQA, HEDIS, UDS, payer, grant, and other applicable requirements.
• Oversee quality incentive programs and reporting.
• Integrate quality improvement, patient safety, risk management, infection prevention, peer review, and compliance activities.
• Chair the Quality Committee and coordinate quality reporting to Executive Leadership and the Board QA Committee.

Quality Data, Reporting & Performance Management

• Oversee collection, validation, analysis, and reporting of quality, risk, compliance, credentialing, and patient safety data.
• Partner with Clinical Leadership and stakeholders to develop quality reports.
• Validate data used for quality and regulatory reporting.
• Monitor KPIs and organizational quality goals.
• Identify trends and translate data into actionable recommendations aligned with strategic and regulatory priorities.

Risk Management & Patient Safety

• Provide organizational leadership for Risk Management and patient safety.
• Identify, assess, prioritize, and mitigate risks affecting patient safety, quality, compliance, operations, reputation, or financial performance.
• Develop and maintain the annual Risk Management Plan and organizational/departmental risk assessments.
• Oversee incident reporting, investigation, escalation, follow-up, and corrective action.
• Lead or facilitate Root Cause Analyses (RCAs), contributing-factor analyses, and other structured investigations.
• Identify recurring events, system failures, and emerging risks and develop strategies to prevent recurrence.
• Ensure significant events are appropriately escalated to leadership and applicable committees.
• Monitor corrective actions arising from incidents, RCAs, audits, and risk assessments for completion and effectiveness.
• Develop risk management policies, procedures, workflows, and monitoring processes.
• Provide risk and patient safety education and consultation to staff and leadership.
• Chair the Risk Management Committee.
• Oversee the FTCA program, including the annual FTCA application and supporting requirements, and monitor medical malpractice insurance outside FTCA.
• Collaborate with legal counsel, insurers, clinical leadership, and Executive Leadership on significant risk matters.
• Promote safety, transparency, accountability, and continuous learning.

Credentialing & Privileging

• Provide organizational leadership and oversight of the Credentialing and Privileging Program.
• Oversee initial credentialing, recredentialing, privileging, and ongoing provider monitoring within required timeframes.
• Establish systems to track credentialing requirements, recredentialing dates, licenses, certifications, and supporting documentation.
• Ensure compliance with HRSA, FTCA, NCQA, CMS, state, payer, and organizational requirements.
• Oversee verification and documentation of provider qualifications, including licensure, education, training, board certification, work history, malpractice history, sanctions, exclusions, and other required information.
• Maintain complete, accurate, current, secure, and audit-ready credentialing files.
• Oversee provider-specific clinical privileges based on education, training, experience, demonstrated competency, scope of practice, and supporting documentation.
• Coordinate initial appointment, reappointment, privilege modifications, temporary and emergency privileges, and other privileging actions.
• Chair or coordinate the Credentialing and Privileging Committee (CPC) and ensure recommendations are documented and presented for required approval.
• Ensure credentialing and privileging decisions are appropriately communicated and documented.
• Monitor compliance and escalate delinquent, incomplete, or high-risk files.
• Partner with Medical, Dental, Behavioral Health, Nursing, and other clinical leaders to evaluate provider competency and scope of practice.
• Coordinate with Provider Enrollment to align credentialing, privileging, enrollment, and onboarding.
• Partner with Human Resources and Operations to prevent practice outside approved credentials, privileges, or scope.
• Identify and mitigate risks related to expired credentials, incomplete files, inappropriate privileges, or unauthorized practice.
• Ensure adverse information, sanctions, complaints, quality concerns, peer review findings, and other relevant information are evaluated for potential impact on appointments and privileges.
• Maintain ongoing provider competency and qualification monitoring.
• Develop and maintain credentialing and privileging policies, procedures, workflows, and monitoring tools.
• Report credentialing compliance, outstanding requirements, privileging status, and identified risks to Executive Leadership and applicable governing bodies.
• Maintain regulatory, accreditation, payer, HRSA, and FTCA readiness for credentialing and privileging reviews.

Compliance & Regulatory Management

• Provide leadership and oversight of the organizational compliance program.
• Ensure compliance with applicable federal, state, and local laws, regulations, funding requirements, and healthcare standards.
• Serve as a primary resource for HRSA, FTCA, HHS, NCQA, CMS, payer, and other regulatory requirements.
• Develop, review, and update compliance policies and procedures.
• Conduct compliance audits, monitoring, and assessments; identify gaps and develop corrective action plans.
• Monitor corrective action implementation and effectiveness.
• Maintain regulatory documentation and evidence of compliance.
• Serve as a primary contact for regulatory correspondence and compliance inquiries.
• Coordinate organizational responses to regulatory requests, audits, surveys, investigations, and corrective actions.
• Monitor regulatory changes and communicate requirements and organizational implications to leadership and staff.
• Provide compliance education and promote ethical conduct, accountability, transparency, and regulatory readiness.

Policy, Procedure & Governance

• Develop, review, revise, and maintain Quality, Risk Management, Compliance, Credentialing, Privileging, and Patient Safety policies and procedures.
• Align policies with regulatory requirements, organizational practices, and evidence-based standards.
• Partner with Clinical Leadership, Operations, and stakeholders on clinical quality, patient safety, and compliance related policies.
• Coordinate appropriate leadership, committee, and Board review and approval.
• Maintain systematic policy review and regulatory-update processes.

Committee & Governance Leadership

• Provide leadership and/or coordination for applicable organizational committees, including:
  • Quality Committee and Subcommittees as appropriate
  • Risk Management Committee and Subcommittees like Safety and Emergency Preparedness Committee
  • Credentialing and Privileging Committee and Peer Review Committee
  • Board Quality Assurance Committee
• Responsibilities include agendas, reports, meeting materials, minutes, action items, follow-up, and regulatory documentation. Committee activities must be structured, documented, and aligned with organizational governance and regulatory requirements.

Leadership & Team Management

• Lead, mentor, and develop Quality, Risk Management, Compliance, and Credentialing functions.
• Establish departmental goals, priorities, performance expectations, and accountability measures.
• Supervise assigned staff and provide coaching, feedback, and performance evaluations.
• Build staff expertise in quality improvement, risk management, compliance, credentialing and privileging, patient safety, and regulatory requirements.
• Foster collaboration, accountability, continuous improvement, and professional development.
• Allocate resources effectively and integrate quality, risk, compliance, and credentialing into daily operations.
• Promote effective communication and shared accountability across clinical and operational teams.
• Develop and provide training in Quality improvement, Patient safety, Risk management, Incident reporting,
• Compliance, Credentialing and privileging, Regulatory requirements, and Policy and procedure compliance
• Identify training needs based on audits, incidents, RCAs, regulatory changes, and performance trends.
• Document required training and education.
• Serve as a subject matter expert and resource for staff and leadership.

Regulatory & External Relations

• Maintain organizational readiness for regulatory and accreditation surveys.
• Coordinate preparation for HRSA, FTCA, NCQA, CMS, payer, and other audits, surveys, and reviews.
• Maintain supporting documentation and evidence of compliance.
• Coordinate responses to regulatory findings and corrective action requirements.
• Monitor grant and funding requirements.
• Stay current with healthcare regulations, accreditation standards, and industry best practices.
• Communicate regulatory changes and organizational implications to leadership.

Reporting & Communication

• Prepare and present reports on quality, risk management, and compliance activities to senior management.
• Communicate effectively with staff, patients, and stakeholders regarding quality, risk, and compliance issues.
• Stay current with industry trends, best practices, and regulatory changes to ensure the organization remains up-to-date and compliant.
• Coordinate Bi-monthly Board Quality Sub-committee, monthly Continuing Quality Management Committee and monthly Sub-committees
• Coordinate and Manage Quality Improvement Projects
• Present Monthly reports to the Quality Committee, Provider group, Health Center Teams, Executive Team, and Board Quality subcommittee which include key Data Reports, progress reporting on Quality Improvement Projects, Risk Management activities and other key Quality Improvement/Assurance activities.
• Develop, update, and maintain Quality Improvement/Assurance and Clinical Application Policies and Procedures and present to the Leadership team for approval as needed.
• Work with Clinical Leadership and Practice Management to create custom reports needed for ongoing maintenance of quality care and operations.
• Respond to Ad hoc internal data requests from Leadership
• Oversee Clinical Applications to ensure quality and data accuracy and cohesive workflows (i.e. EHR, etc.)
• Other duties as assigned

COMPETENCIES

Strategic Leadership

• Translates regulatory and organizational requirements into effective operational systems.
• Develops practical solutions to complex quality, risk, compliance, and provider oversight challenges.
• Anticipates emerging risks and develops proactive mitigation strategies.

Collaboration & Influence

• Builds effective relationships across clinical, operational, and executive teams.
• Demonstrates strong interpersonal and conflict-resolution skills.
• Engage stakeholders in decision-making and process improvement.
• Communicates clearly and persuasively with staff, providers, leadership, and governing bodies.

Analytical & Problem-Solving Skills

• Use data and evidence to identify trends, evaluate performance, and guide decisions.
• Demonstrates strong investigative and root-cause analysis skills.
• Exercises sound judgment when evaluating quality, safety, compliance, and provider-related risks.

Integrity & Accountability

• Demonstrates high standards of ethical conduct and professional integrity.
• Maintains confidentiality and appropriately handles sensitive organizational a