RN Director of Quality & Regulatory Compliance

Posted Yesterday
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Central, TX, USA
In-Office
100K-187K Annually
Mid level
Healthtech
The Role
Directs hospital quality and regulatory compliance activities, including accreditation readiness, regulatory education, performance improvement, committee support, tracers, root cause analysis, FMEA, and improvement-plan execution. Advises departments on professional standards, Joint Commission, AHCA, and CMS requirements; identifies deficient practices and recommends corrective actions. The role also manages sensitive data, reporting, staff education, and quality initiatives.
Summary Generated by Built In

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

All the benefits and perks you need for you and your family:

  • Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance

  • Paid Time Off from Day One

  • 403-B Retirement Plan

  • 4 Weeks 100% Paid Parental Leave

  • Career Development

  • Whole Person Well-being Resources

  • Mental Health Resources and Support

  • Pet Benefits

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

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Skills Required

  • Excellent verbal and written communication skills
  • Ability to work independently and in a team environment
  • Good math skills and ability to work with spreadsheets
  • Ability to handle sensitive and confidential data
  • Proficiency with Microsoft Excel, PowerPoint, Word, Trove or similar databases, database management, and Electronic Medical Record navigation
  • Working knowledge of or ability to learn Joint Commission standards and AHCA/CMS regulations
  • Strong organizational skills, attention to detail, and ability to multitask
  • Education or experience in performance improvement, such as Team Leader, facilitator, Malcolm Baldrige, or Lean Six Sigma
  • Bachelor's degree in a healthcare-related field
  • Master's degree
  • Bachelor's degree in Nursing
  • At least 3 years in a leadership role
  • At least 1 year in human factor analysis
  • At least 3 years in quality and regulatory reporting, performance improvement management, patient safety, and statistical data analysis
  • At least 3 years of experience in a healthcare setting
  • Certified Professional in Healthcare Quality (CPHQ)
  • Registered Nurse (RN) license
  • Enhanced Nurse Licensure Compact RN (ENLC-RN)

AdventHealth Compensation & Benefits Highlights

The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about AdventHealth and has not been reviewed or approved by AdventHealth.

  • Healthcare Strength Comprehensive medical, dental, vision, and pharmacy coverage is offered with multiple plan options and 100% coverage for preventive care. Wellness programs and mental health resources are included to support whole-person well-being.
  • Retirement Support Retirement programs include the Adventist HealthCare Retirement Plan with employer cash contributions and matching for employee contributions. Additional financial protections include disability and life/AD&D insurance and tax-advantaged accounts.
  • Wellbeing & Lifestyle Benefits Whole-person resources feature mental-health support (e.g., Lyra), wellness initiatives, and an Employee Assistance Program. Tuition assistance, education pathways via AdventHealth University, and employee discounts add lifestyle and career value.

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The Company
HQ: Altamonte Springs, FL
80,000 Employees
Year Founded: 1973

What We Do

At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. More than 80,000 skilled and compassionate caregivers in physician practices, hospitals, outpatient clinics, skilled nursing facilities, home health agencies and hospice centers provide individualized, wholistic care. Our Christian mission, shared vision, common values and focus on whole-person health is our commitment to making communities healthier with a unified system: 50 hospital campuses and hundreds of care sites in diverse markets throughout nine states.

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