AdventHealth University

RN Director of Quality & Regulatory Compliance

AdventHealth University$100K — $186K *
Healthcare
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • Bachelor's degree in a healthcare-related field is required; Master's preferred.
  • 3+ years in quality and regulatory reporting, performance improvement management, or patient safety is required.
  • Experience with human factor analysis is preferred, ideally 1+ years.
  • 3+ years in a healthcare setting is preferred, especially in a leadership role.
  • Familiarity with Joint Commission standards and AHCA/CMS regulations is essential.
  • Proficiency in using spreadsheets and database management software, including Microsoft Excel and EMR systems is required.

Responsibilities

  • Facilitate ongoing and special committees/task forces to enhance quality and address regulatory concerns.
  • Serve as a resource for hospital departments on professional standards of practice.
  • Coordinate activities to prepare for Joint Commission, AHCA, and CMS requirements.
  • Oversee execution of improvement plans and support teams in utilizing improvement tools.
  • Identify deficient practices and engage in Root Cause Analysis, providing actionable recommendations.

Benefits

  • Full-time position with Monday to Friday, 8:00 AM to 5:00 PM shifts.
  • Professional development opportunities in performance improvement methodologies.
  • Collaborative work environment with a focus on quality care and patient safety.
Full Job Description
Schedule:
Full time

Shift:
Day (United States of America)

Address:
2201 S CLEAR CREEK RD

City:
KILLEEN

State:
Texas

Postal Code:
76549

Job Description:

Monday - Friday 8:00am - 5:00pm
  • 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.

Knowledge, Skills, and Abilities:
  • Excellent verbal and written communication skills as demonstrated by application resume, work history, and interview process. [Required]
  • Ability to work independently or in a team environment. [Required]
  • Good math skills with an ability to understand and work with spreadsheets. [Required]
  • Ability to work with data that is of sensitive and confidential nature. [Required]
  • 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. [Required]
  • Working knowledge of or ability to learn and work with appropriate Joint Commission standards and AHCA/CMS regulations and information. [Required]
  • Good organizational skills, strong attention to detail, and ability and willingness to multitask. [Required]
  • Education in Performance Improvement such as Team Leader, Facilitator experience, Malcolm Baldrige, and/or LEAN Six Sigma. [Required]


Education:
  • Bachelor's [Required]
  • Master's [Preferred]
  • Bachelor's in Nursing [Preferred]


Field of Study:
  • in healthcare-related field


Work Experience:
  • 3+ in leadership role [Preferred]
  • 1+ in human factor analysis [Preferred]
  • 3+ in quality and regulatory reporting, performance improvement management, patient safety, and statistical data analysis [Required]
  • 3+ in healthcare setting [Preferred]


Licenses and Certifications:
  • Certified Professional in Healthcare Quality (CPHQ) [Preferred] OR
  • Registered Nurse (RN) [Preferred] OR
  • Enhanced Nurse Licensure Compact - RN (ENLC-RN) [Preferred] AND


Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/23km2677

Pay Range:

$100,360.00 - $186,638.40

About AdventHealth University

AdventHealth University is a private university in Orlando, Florida. It was founded in 1992 and is affiliated with the Seventh-day Adventist Church. The university offers undergraduate and graduate degree programs in various fields including nursing, radiography, and sonography. AdventHealth University is accredited by the Southern Association of Colleges and Schools Commission on Colleges.
Learn more about AdventHealth University
Size
1,000 employees
Industry

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