Director – Nursing Clinical Programs and Accreditation

The Director, Nursing Clinical Programs and Accreditation holds 24-hour accountability for the quality of patient care, operational efficiency, and people management across all Culinary Health Center locations. As a senior leader within Culinary Health Operations, the Director is also responsible for designing, implementing, and maintaining operational programs and best practices to ensure compliance with applicable state, federal, and accreditation standards. The Director provides strategic and operational oversight of regulatory compliance, quality improvement, and clinical risk mitigation, supporting the organization's commitment to patient safety and excellence in care. This role includes leadership of programmatic expansion efforts—both for new and existing service lines—and plays a key role in identifying strategic initiatives that drive continuous improvement. The Director serves as a key resource across the organization on matters of quality standards, compliance readiness, and patient-centered care. The Director reports directly to the Executive Administrator, Culinary Health Operations, and serves as a critical connector between clinical excellence, regulatory integrity, and operational strategy.

Essential Duties:

• Regulatory Compliance & Accreditation • Ensures compliance with all applicable federal, state, and local regulations, including but not limited to DNV, CMS, Title 22, and AAAHC standards. • Leads preparation and response for regulatory and accreditation surveys—both scheduled and unannounced—including onsite processes, data reporting, and direct communication with surveyors and regulatory agencies. • Serves as the primary liaison with accreditation bodies, staying current with changing standards and disseminating updates across the organization. • Implements and maintains programs that ensure ongoing survey readiness and regulatory alignment across departments. • Conducts and oversees mock surveys, corrective action follow-up, and training initiatives to build regulatory awareness and accountability at all levels. • Serves as a subject matter expert on accreditation standards and clinical best practices • Leads initiatives to achieve national and organizational benchmarks
• Quality & Performance Improvement • Oversees regulatory compliance and quality improvement efforts • Designs and drives continuous quality improvement (CQI) initiatives and performance improvement projects that support safe, effective, and customer-centered care delivery. • Evaluates the effectiveness of corrective actions and improvement plans; ensures alignment with organizational goals and regulatory expectations. • Partners with leadership to ensure all quality initiatives are data-informed, staff-engaged, and outcome-focused. • Provides training, coaching, and mentorship on quality metrics, compliance, and evidence-based practices to departmental teams.
• Operational & Clinical Leadership – Nursing Programs • Oversees the Transition of Care Program, Diabetic Center of Excellence Program and any other programs as assigned. • Maintains 24-hour accountability for patient care quality, operational efficiency, and resource utilization within assigned departments or units. • Ensures care delivery models and staff design promote effective, legally compliant, and customer-focused service. • Leads the development and monitoring of departmental policies and procedures that support the scope of services, staffing needs, and performance expectations. • Plans for and ensures appropriate levels of qualified, competent staff; addresses recruitment, onboarding, scheduling, and cross-training to optimize workforce flexibility and clinical coverage. • Oversees space planning, resource allocation, and use of external service providers to support departmental operations. • Demonstrates leadership in emergency preparedness and response
• Financial Management • Contributes to the development, analysis, and monitoring of the operational budget; evaluates variances and identifies opportunities for cost-effective care delivery. • Uses financial data to guide operational decision-making and program planning, supporting both service line expansion and sustainability. • Develops and manages budgets, resource allocation, and staffing to ensure financial responsibility and operational effectiveness
• Education & Professional Development • Coordinates the training of nurses and staff in collaboration with the Education Department. • Champions ongoing education and competency development related to regulatory compliance, patient safety, and nursing best practices.
• Culture, Collaboration & Governance • Fosters a culture of shared governance, mutual respect, and professional growth by promoting effective communication and collaboration among nursing staff, physicians, and other departments. • Serves as a coach and mentor, modeling leadership behaviors and promoting a positive, accountable workplace culture. • Participates in setting and evaluating customer service standards, supporting improvements in employee, patient, and physician satisfaction. • Represents nursing leadership on interdepartmental committees, task forces, and strategic planning groups. • Maintains a professional, approachable image and fostering a culture of accountability, innovation, and collaboration • Advocates for the needs of patients and communities served
• Other Duties Performs additional duties as assigned to support the organization’s mission, compliance readiness, and clinical excellence.

Required Qualifications:

• Req Bachelor’s Degree Nursing Degree in Nursing

• Req 5 years Minimum of five years’ experience in a formal management position required
• Req 5 years At least five years’ experience as an RN required.

• Req Excellent communication skills both oral and written.
• Req Committed to excellence in patient care and customer service.
• Req Commitment to continuous quality improvement and results driven outcomes.
• Req Ability to build credibility as a champion for patient care, quality and the professional practice of nursing.
• Req Committed to the development of professional practices.
• Req Organization/time management skills.
• Req Ability to lead change while achieving business goals and objectives.

Preferred Qualifications:

• Pref Master’s degree Nursing Degree in Nursing or in progress, strongly preferred * Master’s Degree in Nursing may be in lieu-of bachelor’s degree in Nursing
• Pref Advanced Cardiovascular Life Support (ACLS) Healthcare Provider from American Heart Association
• Pref Specialty Certification

Required Licenses/Certifications:

• Req Registered Nurse - Nevada State Board Active RN license
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association

The annual base salary range for this position is $133,120.00 - $219,648.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.

USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations, including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance, and with due consideration for patient and student safety. Please refer to theBackground Screening Policy Appendix Dfor specific employment screen implications for the position for which you are applying. 

We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at (213) 821-8100, or by email at [email protected]. Inquiries will be treated as confidential to the extent permitted by law.

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