System Director of Quality Management and Accreditation

Job Title: System Director of Quality Management and Accreditation

Location: Juneau, Alaska



Employment Type: Full-Time, Permanent



Shift: Monday Friday, Days (40 hours/week)



Salary Range: $156,000 $218,000 annually



Sign-On Bonus: $25,000



Relocation Assistance: $10,000

Job Summary

The System Director of Quality Management and Accreditation is responsible for leading and directing the organization's Quality Management, Accreditation, Patient Safety, Risk Management, and Regulatory Compliance programs. This role ensures organizational adherence to accrediting body standards and drives continuous quality improvement across all departments and service lines.

The Director provides strategic leadership to promote a culture of safety, performance excellence, and regulatory compliance while supporting SEARHC's mission of delivering high-quality healthcare services to the communities of Southeast Alaska.

Key Responsibilities

• Lead the development and execution of the Quality Management and Accreditation strategy across the organization

• Oversee compliance with accreditation standards, regulatory requirements, and healthcare quality benchmarks

• Direct infection prevention, patient safety, risk management, employee health screening, and credentialing functions

• Develop and implement quality improvement initiatives using methodologies such as PDSA cycles and performance improvement tools

• Collaborate with Electronic Health Record (EHR) teams to develop and monitor quality metrics and reporting systems

• Analyze quality data and prepare reports for executive leadership and governing boards

• Manage complaint resolution processes, including investigation, analysis, and corrective action planning

• Provide guidance on accreditation standards interpretation and readiness for surveys and audits

• Foster cross-functional collaboration across departments to integrate quality improvement initiatives

• Lead, mentor, and supervise quality management staff to ensure high performance and accountability

• Ensure alignment of quality programs with organizational goals and strategic priorities

• Participate in organizational policy development and continuous improvement efforts

Leadership & Supervisory Duties

• Directly supervise quality management and compliance staff

• Provide coaching, performance management, and professional development support

• Promote a high-performance culture focused on accountability and continuous improvement

Required Qualifications

Education

• RN license or comparable clinical degree required

• Master's degree in healthcare administration, nursing, or business preferred

• Certified Professional in Healthcare Quality (CPHQ) required within 18 months of hire

Experience

• Minimum 5 years of healthcare administration or performance improvement experience

• At least 3 years of supervisory/leadership experience in healthcare settings

Knowledge & Skills

• Healthcare quality improvement and performance management principles

• Accreditation standards (e.g., CMS, Joint Commission, etc.)

• Risk management, patient safety, and infection control practices

• Strong leadership, program planning, and implementation skills

• Ability to analyze data and drive decision-making

• Excellent communication and stakeholder engagement abilities

• Experience working with EHR systems and quality reporting tools

Abilities

• Lead and motivate multidisciplinary teams effectively

• Manage multiple priorities in a fast-paced healthcare environment

• Influence organisational change through collaboration and leadership

• Communicate effectively with executive leadership, staff, and external stakeholders

• Apply critical thinking under pressure and uncertainty

• Understand healthcare financial and ethical decision-making impacts

Additional Information

• Travel required (air, ferry, and small aircraft within the Alaska region)

• Full benefits package includes health, dental, vision, retirement, PTO, life insurance, and disability coverage

• Must be eligible for state licensure upon hire