Director of Quality Management
ScionHealth
Director of Quality Management
ScionHealth
Manages acute and post-acute hospital networks
Kindred Hospital San Antonio Central, is located inside Baptist Medical Center is a long-term acute care (LTAC) hospital specializing in the treatment of patients recovering from post-intensive care and medically complex conditions. Our hospital provides both intensive care and telemetry-level services, offering advanced monitoring and support for patients requiring extended medical care. With a multidisciplinary team dedicated to personalized treatment plans, we focus on helping patients achieve significant recovery and transition to the next level of care.
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.
Kindred Hospital San Antonio Central, is located inside Baptist Medical Center is a long-term acute care (LTAC) hospital specializing in the treatment of patients recovering from post-intensive care and medically complex conditions. Our hospital provides both intensive care and telemetry-level services, offering advanced monitoring and support for patients requiring extended medical care. With a multidisciplinary team dedicated to personalized treatment plans, we focus on helping patients achieve significant recovery and transition to the next level of care.
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.
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)
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)
Manages acute and post-acute hospital networks
ScionHealth runs a network of hospitals that provide both acute and post-acute care. It operates 79 hospital campuses across 25 states, including 61 long-term acute care hospitals and 18 community hospitals, with a focus on patient-centered, quality-driven care. Its services cover the full hospital care path—from immediate treatment to longer-term recovery—using coordinated care teams and technology to support clinicians and improve outcomes. The company differentiates itself by its large, integrated network that combines short-term and long-term care, its community-focused approach, and its emphasis on investing in people and technology to deliver compassionate care. Its goal is to improve health outcomes in communities by offering a seamless continuum of hospital care and expanding access to high-quality services.
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