Position Summary
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.
Quality & Performance Improvement
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.
Regulatory Compliance & Survey Readiness
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 by CMS, 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.
Risk Management
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.
Clinical Staff Education
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.
Regional Facility Support
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 operational and regulatory needs.
Travel Requirements
This position requires frequent and extensive travel to multiple hospital locations within the assigned region. The Regional Quality Manager must be available to travel based on facility needs, scheduled audits, training, survey preparation, regulatory activity, and other quality or operational priorities.
Travel may include multiple overnight stays per week, and the employee must maintain the flexibility necessary to adjust travel schedules based on the needs of assigned facilities. This position requires an active onsite presence and should not be considered a remote or hybrid position.
Qualifications
The successful candidate must possess strong knowledge of healthcare quality management, QAPI, regulatory compliance, risk management, performance improvement, and survey readiness. The position requires excellent leadership, communication, organizational, analytical, and problem-solving skills, as well as the ability to work independently and effectively with leadership teams across multiple facilities. Minimum 2 years experience is required.
Hospital and/or behavioral healthcare experience is strongly preferred. Experience with CMS Conditions of Participation, state regulatory requirements, accreditation standards, Plans of Correction, QAPI, risk management, regulatory surveys, and clinical staff education is highly desirable.
The Regional Quality Manager must demonstrate the ability to identify deficiencies, communicate expectations effectively, provide education and guidance, and hold facilities accountable for implementing and sustaining corrective actions.
