Director Quality Services
Nexus Children's Hospital —Shenandoah, TX
- Full-time
- Nursing
- RN License
- Bachelor of Science
Quick Apply
7d

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Director Quality Services

Nexus Children's Hospital -
Shenandoah, TX

Quick Apply

Job Details

Full-time
7 days ago

Qualifications

Medicare
BLS Certification
CMS regulatory compliance
Hospital accreditation
Medicare regulations
Centers for Medicare and Medicaid Services (CMS)
Medicaid regulations
Medicaid

Full Job Description

Director of Quality Services

Nexus Children's Hospital

About Nexus Children’s Hospital – Shenandoah

Nexus Children’s Hospital – Shenandoah provides specialized pediatric healthcare services in a compassionate, patient-centered environment focused on delivering exceptional clinical outcomes. Our team is committed to bridging medical care, rehabilitation, and behavioral health services while maintaining the highest standards of safety, compliance, and quality for every child and family we serve.

Position Summary

Under the general supervision of the CEO, the Director of Quality Services is responsible for overseeing hospital-wide quality, performance improvement, compliance, accreditation, and patient safety initiatives. This leadership role serves as the facility’s Compliance and Privacy Liaison and collaborates closely with all department leaders to ensure organization-wide compliance with regulatory, accreditation, and operational standards.

The Director of Quality Services plays a vital role in driving continuous improvement initiatives, promoting a culture of safety, and ensuring compliance with DNV standards, Medicare/Medicaid regulations, HIPAA requirements, and hospital policies and procedures.

Job Responsibilities

Performance Improvement & Quality Oversight

Direct hospital-wide Performance Improvement (PI) activities and initiatives.
Monitor, aggregate, and evaluate quality and compliance data.
Educate staff and physicians regarding PI programs, processes, findings, and outcomes.
Facilitate PI teams to improve hospital processes, patient outcomes, and patient safety.
Develop and present quality reports, action plans, and recommendations to leadership teams, committees, and governing bodies.
Assist department leaders with indicator tracking and compliance activities.
Audit medical records to ensure compliance with designated standards and criteria.
Coordinate continual hospital-wide compliance with DNV accreditation standards.
Ensure ongoing review of hospital practices to maintain licensure and accreditation compliance.

Compliance & Risk Management

Serve as the hospital Compliance Liaison and Privacy Liaison.
Ensure compliance with all regulatory agencies governing healthcare delivery and accrediting body standards.
Investigate incidents, occurrences, near misses, and sentinel events with appropriate follow-up and corrective action plans.
Review incident reports and monitor trends for potential risks or concerns.
Conduct internal compliance investigations as needed.
Provide incident and statistical analysis reports to Executive Leadership and the Governing Board.
Work collaboratively with the Safety Officer to implement and maintain patient and employee safety programs.

Operational Leadership

Develop new avenues for facility growth and operational improvement.
Maintain positive and collaborative relationships with physicians and community partners.
Participate in professional and community organizations as a hospital representative.
Assist with development and implementation of emergency preparedness and safety plans including:
- Fire safety
- Hazardous materials
- Disaster preparedness
- Utilities management
- Security
- Medical equipment safety
- Evacuation procedures
Review and respond to recommendations from regulatory and inspection agencies.
Collaborate with department leaders on organization-wide policies and procedures.
Communicate operational concerns and needs to executive leadership as appropriate.
Perform additional duties as assigned.

Position Qualifications

Education

Bachelor of Science in Nursing (BSN) or equivalent clinical background preferred.
Continuing education in nursing practice, patient safety, and quality improvement preferred.
Extensive knowledge of DNV standards and Medicare/Medicaid regulations required.

Experience

Experience in:
- Performance Improvement
- HIPAA Compliance
- DNV Accreditation
- Risk Management
Previous leadership or management experience preferred.
Extensive experience conducting internal investigations and compliance reviews.
Healthcare industry experience required.

Licensure/Certification

Current Registered Nurse (RN) licensure in the State of Texas preferred.
Current AHA/BLS certification required.

Why Join Nexus Children’s Hospital – Shenandoah?

Opportunity to lead hospital-wide quality and compliance initiatives
Collaborative and mission-driven leadership environment
Meaningful impact on pediatric patient safety and outcomes
Growth-oriented healthcare organization committed to excellence
Competitive compensation and benefits package

Quick Apply

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