Regional Director of Regulatory & Quality Services - Corporate
Full-Time
No salary listed
Senior, Expert
Bachelor's, Master's
Plano, TX, USA
In PersonRequires travel up to 75% of the time.
Risk & ComplianceRegulatory Compliance & Ethics
About the job
Requirements
Bachelor's degree in Nursing or a related clinical field.
Current Texas registered nurse license or the ability to obtain one.
Ability to obtain HACP certification within the first year of employment.
Minimum seven years of hospital clinical practice experience plus three to five years in a senior nursing or quality leadership position, or equivalent years of multi-department nursing oversight.
Familiarity with quality management, regulatory reporting requirements, patient safety, regulatory preparedness, case management, and process improvement programs.
Ability to enhance quality care environments, clinical outcomes, and patient, physician, and employee satisfaction.
Ability to read, analyze, and interpret quality, clinical, financial, and other data.
Proficiency in providing leadership, guidance, direction, and oversight to hospital-level quality leaders.
Knowledge of basic case management operations.
Ability to present information and respond to questions from corporate staff, clinical and medical staff, board members, hospital leaders, and coworkers.
Proficient personal computer skills.
Advanced knowledge of regulatory agency standards and ability to help hospitals meet standards and prepare for surveys and inspections.
Awareness of hospital productivity standards and their application within hospitals.
Project management, time management, planning, organizational, attention-to-detail, and follow-through skills.
Ability to identify, investigate, and resolve issues.
Current driver's license and good driving record.
Responsibilities
Support quality, efficient, safe, and regulatory-compliant healthcare services.
Provide primary oversight of facility quality, regulatory preparedness, and excellence in hospitals.
Oversee and serve as team lead for regulatory preparation and mock surveys for STAC facilities involving The Joint Commission, Centers for Medicare & Medicaid Services, CAH CMS, CIHQ, DNV, and HFAP.
Assist hospitals with post-survey action plans, including triennial, state, and mock surveys.
Conduct and arrange post-mock-survey 60- to 90-day validation surveys.
Present mock-survey findings to hospital governing boards 90 days after surveys.
Provide information to the QSR subcommittee of the CHC Board of Trustees quarterly and present data as requested and directed.
Serve as the quality representative during operations assessments.
Support facility chief nursing officers, nursing directors, quality and case management leaders in daily operations, quality initiatives, constituent engagement and satisfaction, patient safety, productivity management, and direction of clinical and quality services.
Develop and monitor facility quality scorecards and report them quarterly in management operations reviews.
Provide leadership support and serve as a resource for quality and performance improvement at CHC facilities.
Develop and maintain the yearly mock-survey master schedule, facility schedules, surveyor assignments, and final-report coordination.
Maintain the constituent satisfaction process, including patient engagement, physician engagement, and culture-of-safety surveys, and assist facilities in addressing identified issues.
Research answers to regulatory questions or obtain expert advice on difficult regulatory questions.
Identify and promote resolution of difficult operational and clinical-care issues.
Provide support to facility CEOs and CFOs as requested.
Provide leadership education, direction, and support to facility nursing and quality leaders.
Occasionally serve in short-term interim executive CHC field-based roles as requested by the vice president of Clinical Services.
Perform miscellaneous duties as assigned.
May oversee PRN employees involved in mock surveys, regulatory preparedness, patient safety initiatives, and constituent satisfaction initiatives.
Measure and report quality results to hospital and corporate teams and participate in corporate-wide and hospital-based performance-improvement activities.
Maintain hospital regulatory accreditations, licenses, and designations in good standing and comply with applicable laws and regulatory requirements.
Desired Qualifications
Master's degree in Nursing or a related field.
Previous consulting experience.
Multi-hospital leadership experience.
Rural or small hospital experience.
Community Hospital Corporation (CHC), recently recognized as a 2025 Dallas Morning News Top Workplace and named to Becker’s list of 165 Top Places to Work in Healthcare, is seeking a Regional Director of Regulatory & Quality Services.
Based out of our beautiful corporate headquarters in Plano, this leadership role offers an outstanding work environment and a vibrant company culture. At CHC, our team enjoys comprehensive benefits, including paid fitness memberships, tuition reimbursement, a generous PTO allowance and free covered parking.
Under the supervision of the VP, Clinical & Quality Services, the Regional Director of Regulatory & Quality Services responsibilities will be:
Supports quality, efficient, safe, and regulatory compliant healthcare services.
Serves as the primary oversight of facility Quality, Regulatory Preparedness, and Excellence in hospitals
Oversees and serves as team lead for regulatory preparation and mock surveys for STAC facilities related to TJC, CMS, CAH CMS, CIHQ, DNV, and HFAP.
Assists hospitals with post-survey action plans, including triennial, state, and mock surveys.
Conducts and arranges post mock survey 60-90 day validation surveys.
Presents mock survey findings to the hospitals Governing Board - 90 days post survey.
Provides information to the QSR subcommittee of the CHC Board of Trustees quarterly and presents the data as requested and directed.
Serves as Quality Representative during Operations Assessments.
Assists in providing support to field CNO's, Nursing Directors, Quality and Case Management Leaders in their daily operations, quality initiatives, constituent engagement/satisfaction, patient safety, productivity management, and direction of clinical/quality services.
Along with VP of Clinical and Regulatory Support, develops and monitors the facility quality scorecards. Reports this quarterly in the MOR reviews.
Provides leadership support and is a resource for quality and performance improvement at CHC facilities.
Develops and maintains mock survey master yearly schedule (with approval by VP Clinical Services), each facility’s schedule with surveyor assignment, and coordinates the final report writing.
Maintains constituent satisfaction process, including patient engagement, physician engagement, and the culture of safety surveys. Assists facilities in developing processes to address identified issues.
Researches answers to regulatory questions or seeks other expert advice when unable to discern difficult regulatory questions.
Identifies and effectively promotes the resolution of difficult operational and clinical care issues.
Provide support to facility CEO’s and CFO’s as requested
Provides leadership education, direction and support to facility Nursing and Quality leaders.
May occasionally serve in short-term interim executive CHC field based roles as requested by the VP Clinical Services.
Other General and Related Duties
Performs miscellaneous duties as assigned
May oversee PRN employees involved in mock surveys, regulatory preparedness, patient safety initiatives, and constituent satisfaction initiatives (patient, physician, and employee engagement).
Supports and applies CHC's core values of Respect, Integrity, Stewardship and Excellence in the performance of job functions.
Upholds and supports the company’s mission, vision, goals, and objectives
Complies with CHC policies and procedures as they relate to the performance of job functions.
Is actively committed to quality of patient care, treatment, and services. Measures and reports quality results to hospital and corporate teams. Fosters continuous quality improvement. Participates in corporate-wide and hospital-based performance improvement activities.
Is actively committed to providing excellent customer service.
Strives to meet or exceed expectations/satisfaction in the performance of job functions.
Is actively committed to meeting and/or exceeding physician expectations/satisfaction in the performance of job functions.
Retains all regulatory related hospital accreditations, licensures and designations in good standing. Maintains compliance with all laws and applicable regulatory requirements. Acts promptly to comply with required changes.
Education / Requirements
Bachelor's degree in Nursing or related clinical field
Masters in Nursing or related field is highly preferred
Must hold current Texas RN license or have the ability to be licensed in the State of Texas
Will require obtaining HACP certification within the first year of employment.
Plano based position
Ability to travel 75% of the time
Experience
Minimum seven years hospital clinical practice experience plus three to five years in a senior nursing or quality leadership position (would consider equivalent years of multi-department nursing oversight)
Previous consulting experience helpful
Multi-hospital leadership preferred
Required familiarity with Quality management, Regulatory Reporting Requirements, Patient Safety, Regulatory Preparedness, Case Management, and Process Improvement Programs
Rural or small hospital experience desirable
Skills and Knowledge
Ability to assist hospitals in enhancing a quality care environment, positive clinical outcomes, and a high level of patient, physician, and employee satisfaction.
Ability to read, analyze and interpret quality, clinical, financial and other data.
Proficient in providing leadership, guidance, direction and oversight of quality leaders at the hospital level.
Has knowledge to support the basic implementation of case management operations.
Communicates well verbally in both formal and informal formats.
Ability to effectively present information and respond to questions from CHC corporate staff members, clinical and medical staff, Board members, hospital leaders, and co-workers.
May participate in hospital administrative teams, quality management directors, case management directors, clinical leaders, and fiscal leaders in decision making structures and processes.
Works with people in such a manner as to build cooperation and group commitments to goals and objectives.
Ability to work independently and manage multiple projects simultaneously.
Ability to respectfully work with all levels of CHC corporate staff, administration, management, staff, and medical staff.
Ability to communicate and relate well with others.
Proficient PC skills.
Advanced knowledge of regulatory agency standards and the ability to assist hospitals in meeting standards and prepare for surveys and inspections.
Awareness of hospital productivity standards and how to apply them within hospitals.
Excellent project management, time management and planning skills.
Effective organizational skills, attention to detail, and effective follow-through on responsibilities and requests.
Ability to identify, investigate and resolve issues.
Possess a high degree of political savvy.
Ability to travel up to 70% of the time.
Current driver's license and good driving record.
A comprehensive health and welfare benefits package is offered as part of total compensation.
Health Care Plan (Medical, Dental & Vision)
Retirement Plan (401k, IRA)
Life Insurance (Basic, Voluntary & AD&D)
Paid Time Off (Vacation, Sick & Public Holidays)
Wellness Resources and other benefits
CHC is a tobacco and drug free workplace. We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.