Associate Director of Healthcare Quality and Compliance

The Associate Director of Healthcare Quality and Compliance is a leadership role responsible for overseeing the development, implementation, and continuous improvement of quality management, safety and risk, and compliance programs within the healthcare organization. This position plays a critical role in ensuring the organization meets regulatory requirements, adheres to industry best practices for quality, privacy, and compliance, and consistently delivers high-quality, patient-centered care. The Associate Director will collaborate with various departments to ensure that all healthcare practices are aligned with accreditation standards, safety protocols, and regulatory guidelines, driving overall quality improvements across the organization.

Duties/Responsibilities

Below are the primary duties and essential functions of an employee in this position. While not all tasks may be performed by every employee in this role, all employees are expected to perform related tasks as needed. These essential functions must be performed with or without reasonable accommodation.

• Ability to lead, collaborate, and support high functioning team within the Healthcare Quality areas as well as outpatient leadership teams and other support departments.
• Implement strategies for a quality infrastructure, ensuring effective use and protection of privileged or confidential information in accordance with regulations, with Knowledge and practical application of HIPAA and 42CFR rules.
• Develop, implement, and maintain a comprehensive privacy and compliance program, ensuring alignment with organizational goals, regulatory standards, and accreditation requirements.
• Monitor and ensure adherence to all local, state, and federal regulations, including CMS, HIPAA, OSHA, and other healthcare-related compliance standards. Ensure team can conduct regular audits and assessments to identify areas for improvement and ensure compliance, with a high emphasis on trend analysis and action planning for areas of improvement.
• Collaborate with teams to enhance processes during care transitions for improved patient outcomes, ensuring each area of the organization has an emphasis on process improvement.
• Drive efforts for data collection and analysis to monitor clinical performance, identify opportunities for improvement, and implement evidence-based practices to support a team able to drive results at the local level.
• Foster a culture of quality throughout the organization by providing leadership, training, and support to clinical and non-clinical teams, ensuring that quality and privacy and compliance metrics are met and sustained.
• Design and deliver training programs to educate staff on quality improvement practices, compliance regulations, and safety protocols. Promote a culture of continuous learning and quality enhancement within the organization.
• Implement Quality Management program strategies and action planning for the organization, ensuring data analysis from local leadership is addressed to ensure KPI compliance and performance improvement metrics.
• Knowledge and ability to use a PDCA approach to implement solution to improve patient safety and quality of care.
• Oversee the collection and analysis of data related to quality and compliance, including safety incidents, clinical outcomes, and regulatory performance. Prepare detailed reports and present findings to senior leadership, providing actionable insights for strategic planning.
• Collaborate with the safety and risk management teams to identify potential risks to patient safety and organizational compliance. Lead initiatives to mitigate risks and promote a proactive approach to patient safety.
• Work closely with clinical, operational, and administrative teams to integrate quality and compliance practices into day-to-day operations. Act as a resource for staff, offering guidance and support on quality and regulatory matters.
• Uphold ethical standards while continuously developing professionally through ongoing learning and staying current with industry best practices.
• Collaborate with leadership to develop, review, and update policies, procedures, and protocols to ensure compliance with healthcare regulations and industry best practices. Ensure that these policies are communicated effectively to all staff.
• Any other duties, as assigned.
  
  

Required Qualifications

• Education: Bachelor’s degree in business, medical records, nursing or other health related discipline required. Master’s degree in related field preferred.
• Certificate or Professional License: Prefer certification in an HCQ related discipline, i.e. CPHQ, RHIA, RHIT, RN, LPN, CCP, etc.
• Experience: Minimum of 2 years in a healthcare quality setting.
• Valid driver’s license and active liability insurance.
• Satisfactory results from criminal and driving record background checks
• Must be a minimum 21 years of age.
  
  

As a State-Of-the-Art Healthcare Organization and a Federal Contractor Agency – we require all individuals who join Team Bowen to receive a flu shot and TB test to further protect our staff and the patients we serve. There are options for exemption applications, but approval is not always guaranteed.

Promise of Equal Opportunity and Fostering a Fair and Respectful Workplace:

Bowen Health is an equal opportunity employer committed to fostering an inclusive, diverse and respectful workplace. We comply with all applicable laws, including the ADA and OSHA regulations, and provide reasonable accommodations for qualified individuals with disabilities. Safety is a priority for all employees.

Bowen Health prohibits discrimination based on race, color, religion, sex, national origin, age, disability, genetic information, veteran status, sexual orientation, gender identity, or other protected statuses. Bowen Health is dedicated to creating opportunities for all employees to thrive and support our mission of compassionate care.