At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge, and we lean into new ideas by embracing curiosity and asking questions. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary 

Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and the Governing Body. Facilitates performance improvement and continuous quality improvement (CQI) activities throughout the hospital. Acts as a resource to the administrative team, department managers, and medical staff. Performs clinical risk management functions and assists department managers with preparation for medical staff committees. Maintains oversight responsibility for all regulatory body surveys, including The Joint Commission (TJC), State Licensing Reviews, and CMS Validation surveys. Serves as the Facility Ethics & Compliance Officer.

Essential Functions

• Plans, implements, and oversees the hospital-wide performance improvement program to meet organizational goals.
• Facilitates performance improvement and CQI activities through collaboration with clinical leadership, department managers, ancillary services, the administrative team, and the Governing Body.
• Maintains awareness of regulatory changes and ensures alignment with current accreditation standards and best practices.
• Oversees preparation for regulatory surveys and audits; educates departments to ensure compliance with applicable requirements.
• Uses database systems to document occurrences, medical staff review activities, and committee actions, and prepares reports for leadership and committees.
• Communicates effectively with physicians, staff, CCO, and administrative leadership regarding quality and compliance initiatives.
• Collaborates across departments to support patient care improvement and organizational performance initiatives.
• Participates in risk management and patient safety activities.
• Provides support to medical staff officers, committee chairs, and the Governing Body as needed.
• Serves as primary liaison to the Regional Compliance Director and acts as the main point of contact for compliance-related questions or concerns.
• Escalates compliance issues appropriately and participates in regular compliance reviews and discussions.
• Prepares and submits quarterly compliance reports to facility leadership and the Regional Compliance Director.
• Ensures CMS, NHSN, and other quality reporting requirements are accurate, complete, and submitted timely.

Knowledge/Skills/Abilities/Expectations

• Excellent oral and written communication and interpersonal skills.
• Basic computer skills with working knowledge of Microsoft Office and related systems.
• Knowledge of federal, state, and local healthcare regulations and compliance requirements.
• Understanding of accreditation standards and performance improvement methodologies.
• Strong critical thinking, prioritization, and time management skills.
• Ability to work under stress and respond effectively in urgent situations.
• Ability to travel as required. 0%

Education

• Bachelor’s Degree in a healthcare-related field (required) And

• Bachelor’s Degree in Nursing (preferred)

Licenses/Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the state of practice, Upon Hire (preferred) And

• CPHQ - Certified Professional in Healthcare Quality Upon Hire (preferred)

Experience

• 3+ years of experience in Quality and/or Risk Management in a hospital setting (required)