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Director of QualityRisk
Job Location:
Monthly Salary:
Experience Required:
Posted:
5 July 2026 (30+ days ago)
Posted:
Application Deadline:
2 October 2026
Application Deadline:
Vacancies:
1 Vacancy
Vacancies:
Job Summary
Responsible for governing the facilities regulatory compliance programs and takes the lead role in planning organizing and managing effective quality/performance improvement and risk management functions for all departments and divisions of ORHC
Is the Patient Safety Officer and Patient Safety Field Manager for the facility
Develops the National Quality Program with senior leadership
Prepares monthly operating review quality and patient safety slide deck with details of the current state and focus on the future goal attainment action steps
Facilitates the external surveys from accreditors licensure verifications certifications including mock surveys and those that occur related to complaints reviews annual biennial triennial
Manages the readiness for survey programs
Maintains regulatory readiness and conducts educational programs related to these
Responsible for the electronic educational program for the organization
Responsible for the infection control prevention and surveillance program
Assures that programs initiatives processes and policies are in compliance with state federal and other accrediting bodies/regulatory agencies. Collaborates with facility leaders in expected unannounced active and ongoing survey readiness
Is the administrator for the federal Harp formerly QNet program policy management software program and incident reporting system
Holds responsibility to conduct the Leapfrog Patient Safety program through the leadership for the facility
Engages medical staff directors managers front line staff and Board of Directors to develop implement and maintain a successful written organization-wide quality and risk programs
Manages data collection to evaluate organizational outcomes and submits accurate data in a timely manner as required by regulatory agencies or as part of any volunteer/collaborative initiative
Responsible for tracking and trending incidents assuring ongoing process improvement and follows up with further investigation when appropriate reports information to senior management Medical Staff Board of Directors and/or Quality Committee as appropriate
Assists in the implementation of departmental quality initiatives and analysis of outcomes data. Analyzes shares and assists with interpretation of outcomes data with appropriate staff medical staff and customers. Facilitates any action deeper analysis (root cause analyses) process review or policy change as indicated for any noted undesirable data/negative trends
In collaboration with CNO assists in design and implementation of strategies to measurably improve quality of care for patients served
Assures appropriate level of understanding awareness and compliance with all applicable Joint Commission CMS state and local agency laws internal/external regulations guidelines policies procedures and professional standards
Coordinates the organizational Foundational Five Program
Working with Human Resources analyzes the Culture of Safety survey results and utilizes the results in planning education and coordination of process improvement activities
Must have knowledge of state and federal regulations (federal law DEA OSHA CMS OIG etc.) and expert knowledge of The Joint Commission standards and accrediting licensure verification certification for programs of the facility (CAP CARF AAAHC ACHC as applicable)
Requirements
Masters degree in Nursing other healthcare related fields required
Clinical degree (RN) required
CPPS within one year of hire and CPHQ certification preferred
5 years of leadership and/or management experience in a healthcare setting in nursing risk and/or quality improvement.
Benefits
Medical insurance
Dental insurance
Vision insurance
Life insurance
Retirement
Paid time off
