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Director - Quality and Regulatory Compliance in Rutherfordton, NC at Rutherford Regional Health System

Date Posted: 4/17/2019

Job Snapshot

Job Description

Rutherford Regional Health System

The Director of Quality and Regulatory Compliance is responsible for ensuring that the facility remains in compliance with Joint Commission, state and federal standards; oversight responsibility for all regulatory body surveys, i.e., Joint Commission, State licensing Reviews, CMS Validation Surveys, health department, local regulatory reviews (fire marshal), and any other regulatory activity that may involve the facility. This responsibility includes staying current with Joint Commission, state, and local standards; educating facility staff about standards; and preparing the facility for such accreditation surveys. 

Plans and coordinates quality and regulatory compliance activities to assure appropriate, high quality and regulatory compliant healthcare delivery. This includes development and implementation of hospital-wide Quality Assessment/Performance Improvement plans. Evaluation of effectiveness of corrective actions for identified problems and continuous quality improvement activities. Coordinates assessment of clinical practice patterns for purposes of medical staff credentialing and reappointment. Supervises staff responsible for coordinating a hospital-wide program aimed at compliance with Joint Commission core measure and Medicare quality initiatives.

Job Requirements

Bachelor's Degree required
Master's Degree preferred

Basic Life Support
Certification as a Professional in Healthcare Quality (CPHQ) through National Association for Healthcare Quality (NAHQ) or completion within two (2) years of hire. Must maintain certification throughout employment.

Current, unrestricted license to practice in NC (NC licensure or multi-state [compact] license).
Three years of leadership experience in acute hospital setting required. Two years’ experience leading quality/performance improvement and Joint Commission/CMS survey preparation and coordination required. Knowledge of medical staff oversight/credentialing preferred.

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran


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