Baptist Memorial Health Care · 3 months ago
Administrative Quality & Compliance Director
6225 Humphreys Boulevard, Memphis, TN, 38120, US
Full-time
Onsite
Lead/Staff, Director/Executive
5+ years expBaptist Memorial Health Care is a healthcare organization seeking an Administrative Quality & Compliance Director. This role is responsible for overseeing quality, compliance, risk management, patient safety, and patient experience activities within the hospital, ensuring adherence to accreditation requirements and managing relationships with medical staff.
GovernmentHealth CareHospitalMedicalNon ProfitNursing and Residential CareRehabilitationWellness
Responsibilities
Develops and implements strategy relating to matters of quality, outcomes and experience, and for identifying and mitigating risks to the patient and/or staff. Creates and manages major elements of the Strategic A3s relating to Right Care and Patient Experience
Oversees all activities relating to complying with the requirements for hospital accreditation and licensure. Interfaces directly with JCAHO, the Tennessee Department of Health, and CMS as necessary
Oversees the hospital’s benchmarking programs including NPIC, CWISH, Solutions for Patient Safety and Vermont-Oxford. Is the hospital’s point of contact and manages the hospital’s engagement with Leapfrog, Premier, and Quest
Oversees the hospital’s response to, and resolution of grievances filed in the public domain
Administers the hospital’s adverse incident process. Oversees the investigation and evaluation of incidents, including the taking of corrective actions as needed. Identifies trends and other factors that may influence policy development
Oversees the discovery process in cases with the potential for claims against the hospital. Is involved in all aspects including evaluation and assessment, the consideration of defense strategies, and the recommending of settlements or other actions
Designs programs and oversees the orientation and education of staff in matters of quality, regulatory compliance, patient safety, and patient experience
Is the primary liaison with the medical staff in matters of quality, regulatory compliance, investigation of claims and actions, and patient experience. Is the hospital’s representative to the Peer Review, Perinatal Quality and Pediatric Quality Committees
Assists the medical staff office in matters relating to credentialing, the delineation of privileges, the medical staff bylaws and rules and regulations, and the disciplinary process
Is the primary interface with the corporate departments responsible for quality, compliance, risk management, patient safety and patient experience at the system level
Evaluates the results of the patient satisfaction survey, and prepares plans to improve the hospital’s performance
Participates in community health activities including mortality review, planning for events impacting the health status of the citizenry, and in the adoption and administration of regulations affecting the hospital
Prepares and oversees the budget for the assigned areas of responsibility. Recommends programs and expenditures that can influence outcomes, experience, and/or the mitigation of risk
Develops and administers policy relating to quality, compliance, risk management, patient safety and patient experience
Qualification
Required
Five (5) years of clinical experience as a registered nurse or healthcare management with previous experience in Quality, Risk and/or Compliance
Completion of a baccalaureate, associate or diploma degree in health-related field
Knowledge of licensure and accrediting requirements; ability to communicate and work effectively with medical staff, department heads and administration; excellent organizational skills and problem solving abilities
Registered Nurse
Preferred
5 years experience in quality, risk or compliance; baccalaureate, associate or diploma degree in a health-related field, nursing preferred; Certified Professional in Healthcare Risk Management (CPHRM)
Baccalaureate degree - Nursing preferred
Company
Baptist Memorial Health Care
Baptist Memorial Health Care is a non profit company that provides skilled nursing, rehabilitation, cardiac, and clinical services.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Jason Little
President and CEO
Recent News
HealthCareIT News
2025-12-19
2025-06-21
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