Director of Quality, Compliance & Risk

Job Description

Job Description

Director of Quality, Compliance & Risk

Reports to: Chief Executive Officer Status: Exempt

Location: Crook County Medical Services District

Position Summary

The Director of Quality, Compliance, & Risk provides strategic leadership and oversight for the organization's Quality Assurance and Performance Improvement (QAPI), regulatory compliance, enterprise risk management, and patient safety. This position promotes a culture of safety, accountability, continuous improvement, and organizational excellence across clinical and non-clinical departments. This Director position collaborates with executive leadership, medical staff, department leaders, and employees to maintain regulatory readiness, improve performance, strengthen workforce capabilities, and implement sustainable programs and services that meet organizational and community needs.

Essential Duties/Responsibilities:

Essential duties and requirements include the following. Other duties may be assigned:

Quality Improvement & Performance Excellence

• Direct and oversee the organization-wide QAPI program and related performance improvement activities.
• Establish, monitor, and report quality measures, patient safety indicators, benchmarks, dashboards, and organizational performance goals.
• Lead or coordinate performance improvement projects, root cause analyses, corrective action plans, and evaluation of sustained effectiveness.
• Analyze clinical, operational, patient experience, and financial data to identify trends, risks, and improvement opportunities.
• Prepare and present quality and performance reports to executive leadership, committees, medical staff, and the governing body as appropriate.
• Promote evidence-based practices, interdisciplinary participation, and a culture of continuous improvement.

Regulatory Compliance & Accreditation

• Lead the organizational compliance program and maintain readiness for regulatory, licensing, and accreditation surveys.
• Monitor applicable federal and state requirements, CMS Conditions of Participation, HIPAA, OSHA requirements, and other standards relevant to organizational operations.
• Coordinate compliance audits, mock surveys, documentation reviews, corrective actions, and follow-up monitoring.
• Oversee policy and procedure review, approval workflows, version control, and regulatory alignment.
• Maintain confidential reporting pathways and support non-retaliation, investigation, and corrective action processes.
• Provide compliance reports, education, and recommendations to leadership and governing bodies.

Risk Management & Patient Safety

• Direct the enterprise risk management and patient safety programs.
• Oversee incident, adverse event, near-miss, grievance, and safety concern reporting, investigation, trending, and follow-up.
• Conduct risk assessments and develop mitigation strategies for clinical, operational, environmental, privacy, and organizational risks.
• Promote Just Culture principles and employee participation in safety reporting and risk reduction.
• Coordinate required risk management program evaluations and monitor corrective actions for effectiveness.
• Collaborate with legal counsel, insurers, and organizational leaders as authorized regarding claims, liability, and risk concerns.

Data, Reporting & Governance

• Develop and maintain executive dashboards, scorecards, trend analyses, and reports for assigned programs.
• Ensure integrity, confidentiality, and appropriate use of quality, compliance, risk, training, and operational data.
• Chair, coordinate, or participate in quality, compliance, risk, education, and organizational development committees as assigned.
• Support strategic planning, annual program evaluations, policy governance, and reporting to executive leadership and the governing body.

Leadership & Supervision

• Serve as a collaborative member of the leadership team and an advisor on quality, compliance, risk, development, training, and service growth.
• Provide direction, coaching, and performance oversight for assigned staff and contracted resources.
• Develop annual goals, work plans, budgets, and resource recommendations for assigned functions.
• Maintain professional competence and confidentiality and model ethical, respectful, and accountable leadership.

Education

• Bachelor's degree in healthcare administration, nursing, public health, business administration, organizational development, quality management, or a related field required.

• Master's degree in healthcare administration, business administration, nursing, public health, organizational development, education, or a related field preferred.

Experience, Knowledge, Skills, and Abilities

• Minimum of seven years of progressive healthcare experience, including at least three years in a leadership role involving quality, compliance, risk management, organizational development, education, operations, or service line development preferred.
• Experience in a Critical Access Hospital, Rural Health Clinic, EMS, long-term care, or integrated rural healthcare environment preferred.
• Demonstrated knowledge of healthcare quality improvement, patient safety, compliance, risk management, adult learning, change management, project management, and program development principles.
• Ability to interpret regulations and standards, analyze complex information, manage multiple priorities, and communicate recommendations clearly to varied audiences.
• Experience preparing for regulatory surveys, leading corrective action activities, and developing measurable performance improvement initiatives preferred.
• Professional certification such as CPHQ, CHC, CPHRM, CPPS, Lean Six Sigma, or PMP preferred or willingness to obtain an applicable certification.