Regional Quality Manager

The Regional Quality Manager is responsible for providing quality, regulatory compliance, risk management, performance improvement, and staff education support across multiple assigned hospital facilities. This position works under the direction of the Corporate Quality Director and partners closely with Hospital Administrators, Directors of Nursing, facility Quality Managers, department leaders, medical staff, and other members of hospital leadership to ensure consistent implementation of organizational quality standards and regulatory requirements.

This is a regional, facility-based position requiring frequent travel between assigned locations. The Regional Quality Manager is expected to maintain an active presence within each assigned facility based on operational needs, regulatory priorities, survey readiness, identified deficiencies, and direction from Corporate Quality. This position is not a remote or hybrid role.

The Regional Quality Manager provides oversight and support for Quality Assessment and Performance Improvement (QAPI) activities throughout assigned facilities. The position reviews facility quality data, identifies trends and areas of concern, assists with the development of performance improvement initiatives, and monitors corrective actions to ensure improvements are implemented and sustained.

The Regional Quality Manager works with facility leadership to ensure QAPI activities are meaningful, measurable, properly documented, and aligned with organizational and regulatory expectations. This position serves as a resource to facility leadership and provides guidance, education, and accountability related to quality management and performance improvement.

The Regional Quality Manager supports continuous regulatory compliance and survey readiness across all assigned facilities. Responsibilities include conducting facility audits, identifying compliance deficiencies, assisting with corrective action plans and Plans of Correction (POCs), and monitoring facilities to validate that corrective actions have been successfully implemented and sustained.

The position assists assigned facilities with preparation for regulatory, licensing, accreditation, and validation surveys, including surveys conducted byCMS, state licensing agencies, and applicable accrediting organizations. The Regional Quality Manager may also be required to travel to a facility on short notice in response to regulatory surveys, significant compliance concerns, or other operational needs.

The Regional Quality Manager assists with the identification, evaluation, monitoring, and mitigation of clinical and operational risks throughout assigned facilities. This includes reviewing incidents and trends, supporting investigations and root cause analyses, monitoring corrective actions, and providing education designed to reduce risk and improve patient and employee safety.

The position collaborates with the Corporate Quality Director, facility administration, clinical leadership, and other appropriate parties regarding actual or potential risk situations and assists facilities with implementing effective interventions and monitoring processes.

The Regional Quality Manager identifies educational opportunities based on audits, regulatory findings, quality data, incidents, performance trends, and facility needs. The position provides or coordinates education for hospital leadership and staff regarding quality standards, regulatory requirements, risk management, patient safety, documentation, policies and procedures, and performance improvement expectations.

The Regional Quality Manager works with facility leadership to ensure identified education and corrective training are completed, documented, and evaluated for effectiveness.

The Regional Quality Manager maintains regular communication with leadership at each assigned facility and provides hands-on support based on facility needs and organizational priorities. The position conducts onsite reviews, evaluates compliance with established processes, assists leadership with resolving identified deficiencies, and communicates significant findings and recommendations to the Corporate Quality Director.

The Regional Quality Manager is responsible for helping establish consistency and accountability across assigned facilities while recognizing facility-specific…