SUMMARY
The Director of Enterprise Quality Assurance and Performance Improvement provides strategic leadership for the organization’s quality management systems, certification initiatives, and performance improvement programs. This role is responsible for establishing and maintaining enterprise-wide quality standards, ensuring compliance with contractual and regulatory requirements, and driving continuous improvement across all programs and corporate functions.
The Director of Enterprise Quality Assurance and Performance Improvement shall serve as the organization’s lead for third-party certifications and external audits, including ISO, CMMI, and other applicable frameworks, and advises executive leadership on quality, compliance, and operational risk. This role requires deep experience supporting regulated healthcare environments, including Joint Commission accreditation, Correctional Health programs, and/or Centers for Medicare & Medicaid Services (CMS) regulatory frameworks, ensuring alignment with clinical quality, patient safety, and compliance standards.
DUTIES AND FUNCTIONS
- Lead the development, implementation, and continuous improvement of the organization’s enterprise quality management system (QMS) across all programs and corporate functions.
- Own and execute the organization’s certification strategy, including ISO (e.g., ISO 9001, ISO 27001), CMMI, and other applicable frameworks. Oversee readiness, gap assessments, corrective actions, and ongoing surveillance audit activities.
- Serve as the primary liaison with external auditors, certification bodies, and assessors, ensuring successful audit outcomes and sustained compliance.
- Ensure alignment of quality systems with federal contract requirements, including FAR/DFARS provisions, Performance Work Statements (PWS), and Quality Assurance Surveillance Plans (QASP).
- Drive quality performance to support strong Contractor Performance Assessment Reporting System (CPARS) ratings and overall contract success.
- Lead and support organizational readiness for Joint Commission surveys, CMS audits, and other healthcare regulatory reviews, ensuring continuous compliance with applicable standards.
- Provide oversight and quality guidance for Correctional Health programs, ensuring adherence to federal, state, and accrediting body requirements related to patient care, safety, and documentation.
- Interpret and operationalize CMS Conditions of Participation (CoPs) and other healthcare regulatory requirements into enterprise quality management systems, policies, and performance improvement initiatives.
- Partner with Information Security and IT teams to support compliance with NIST, CMMC, and related cybersecurity frameworks as part of integrated quality and compliance systems.
- Establish and monitor enterprise-wide key performance indicators (KPIs), dashboards, and reporting structures to support data-driven decision-making and executive oversight.
- Lead internal audit programs, external audit readiness efforts, and corrective/preventive action programs across the organization.
- Identify trends, risks, and performance gaps through data analysis and implement corrective action plans to address deficiencies.
- Collaborate with executive leadership, operations, contracts, and business development teams to integrate quality strategies into day-to-day operations and long-term growth initiatives.
- Oversee incident reporting, root cause analysis, and enterprise risk mitigation efforts.
- Develop and deliver training programs to promote a culture of accountability, compliance, and continuous improvement.
- This position will support the delivery of enterprise level training but shouldn't get tasked with content development from a QA seat.
EDUCATION AND EXPERIENCE
- Bachelor’s degree in healthcare administration, nursing, public health, business administration, or related field required.
- Master’s degree preferred.
- Minimum of 10 years of progressive experience in quality assurance, performance improvement, or compliance within a healthcare, correctional health, or federal contracting regulated clinical, or similarly complex environment.
- Direct experience with Joint Commission accreditation processes, CMS regulatory compliance, and/or Correctional Health quality programs strongly preferred.
- Demonstrated experience supporting clinical quality programs, patient safety initiatives, and regulatory survey readiness in complex healthcare delivery settings.
- Demonstrated experience leading organizations through third-party certification processes, including ISO and/or CMMI, with successful audit outcomes.
- Experience supporting federal contracts and working within FAR/DFARS-regulated environments strongly preferred.
- Experience with enterprise quality systems spanning multiple programs, locations, and functional areas
- Experience working with government healthcare systems (e.g., VA, DoD) preferred.
CERTIFICATIONS
- Certification in quality or performance improvement (e.g., CPHQ, Lean Six Sigma, or equivalent).
- ISO Lead Auditor or Lead Implementer certification strongly preferred.
- CMMI-related certification or hands-on appraisal experience preferred
- Hands-on experience with accreditation and regulatory bodies such as The Joint Commission, CMS, NCQA, or CARF, including survey preparation, remediation, and ongoing compliance management. Familiarity with healthcare data analytics tools and reporting systems.
KNOWLEDGE/SKILLS/ABILITIES (KSA)
Strong knowledge of quality management systems, certification frameworks (ISO, CMMI), and continuous improvement methodologies.- Strong knowledge of healthcare regulatory standards, including Joint Commission accreditation requirements, CMS Conditions of Participation, and Correctional Health compliance frameworks.
- Working knowledge of federal contracting requirements, including FAR/DFARS and contract-driven quality obligations.
- Familiarity with NIST frameworks and CMMC requirements.
- Exceptional analytical, problem-solving, and decision-making capabilities.
- Ability to translate complex data into actionable insights for executive leadership.
- Ability to translate clinical and regulatory requirements into enterprise quality strategies and measurable performance outcomes.
- Strong leadership and organizational influence skills, with the ability to drive change across diverse stakeholders.
- Excellent written and verbal communication skills, including executive-level reporting
SUPERVISORY RESPONSIBILITIES
- Leads and develops a team of quality assurance and performance improvement professionals.
- Responsible for hiring, coaching, performance management, and professional development of assigned staff.
WORK ENVIRONMENT/CONDITION
- Standard office setting with typical lighting, temperature, and equipment.
- May require travel to program sites, client locations, or audit reviews.
- Extended periods of computer use, meetings, and collaboration with internal and external stakeholders.
PHYSICAL DEMANDS
- Standard office-related activities, including sitting, standing, and computer use.
- This position operates in a professional office environment with regular interaction across corporate and program sites.
- Requires regular travel (approximately 25%) to program locations throughout the nation, on-site audit oversite, and corporate offices in Orlando, Florida.
- Preferred location is Orlando, Florida. Candidates local to the area or willing to relocate are strongly preferred.
About Loyal Source
Loyal Source provides healthcare and technology solutions designed to improve outcomes and support mission-critical operations. Guided by innovation and purpose, we help organizations achieve success across complex challenges worldwide. Loyal Source is a military friendly employer and proud partner of the Military Spouse Employment Partnership program.
Loyal Source uses AI‑powered voice screening as part of our application process. After you apply, you will receive a brief qualification survey via text or email. Candidates who meet the position requirements will then be invited to complete a quick AI‑powered voice assessment. This easy, no‑scheduling‑required process helps us and the candidate move the hiring process forward faster.
We are committed to providing equal employment opportunities to all applicants. If you have a disability or medical condition and need a reasonable accommodation to participate in this step of the hiring process, you may request an alternative method or accommodation at any time by contacting Human Resources at [email protected].
