Job Summary
Refugio County Memorial Hospital District is recruiting an accomplished healthcare leader to join us as our Chief Quality & Compliance Officer (CQCO). As a key member of the executive leadership team, this individual program management position provides executive architecture, oversight and technical direction of our Critical Access Hospital’s (CAH) enterprise-wide Quality Assessment and Performance Improvement (QAPI) program, corporate compliance program, continuous survey readiness efforts, clinical risk management program and coordination of clinical staff education initiatives. As an individual contributor role with no direct personnel management, the CQCO collaborates with all administrative, clinical and ancillary departments to evaluate outcomes, lead RCA’s, ensure compliance with CMS/state regulations and clearly communicates risk to the CEO and Governing Board. The ideal candidate will have a BSN in Nursing, Healthcare Administration or related field (MSN preferred) and be a current Texas RN license holder. Must have five or more years of progressive clinical experience and acute-care quality/compliance leadership.
Position Purpose and Essential Responsibilities
● Establish, maintain, and evaluate an integrated hospital-wide Quality Assessment and Performance Improvement (QAPI) program compliant with CMS Critical Access Hospital Conditions of Participation (42 CFR § 485.635).
● Architect and oversee the corporate compliance program across all clinical, administrative, and financial operations.
● Direct continuous survey readiness for CMS, Texas Health and Human Services Commission (HHSC), and applicable accrediting bodies.
● Provide integrated Clinical Risk Management, including identification, claims coordination, root cause analysis (RCA), and failure mode effects analysis (FMEA).
● Coordinate clinical staff competency frameworks, mandatory education programs, and academic affiliation agreements.
● Deliver objective data analytics, performance trending, and risk evaluations directly to the CEO and Governing Board.
● Develops, updates, and evaluates the annual QAPI plan to ensure it covers the scope and complexity of all CAH clinical, ancillary, swing-bed, and contracted services.
● Establishes standardized processes for Plan-Do-Study-Act (PDSA) cycles, Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and Hazard Vulnerability Analyses (HVA).
● Facilitates the Quality Committee; compiles agendas, executive dashboards, action logs, and comprehensive meeting minutes for administration and the Governing Board.
● Coordinates clinical outcome reporting, peer review processes across clinical service areas, and QIP measure tracking.
● Maintains the hospital’s centralized performance improvement inventory and tracks corrective action plans (CAPs) for evidence of sustained outcome improvements.
● Integrates patient safety, infection prevention, medication safety, utilization review, and medical staff quality initiatives into the overarching QAPI framework.
● Maintains a continuous regulatory readiness program covering CMS CAH Conditions of Participation, CMS SOM Appendix W, Texas hospital licensing rules, EMTALA, HIPAA, and OSHA standards.
● Conducts mock surveys, tracer audits, environmental rounds, personnel record compliance checks, and medical record audits.
● Oversees preparation for all external surveys (CMS validation, State licensing, accrediting bodies) and coordinates official survey responses.
● Assists department leaders in formulating systemic Plans of Correction (POC) with clear monitoring methodologies, completion dates, and sustainability evidence.
● Escalates actual or potential Immediate Jeopardy (IJ) concerns, condition-level deficiencies, or severe compliance breaches directly to the CEO.
● Develops and evaluates the corporate compliance plan, code of conduct, annual work plan, and compliance risk assessment following OIG General Compliance Program Guidance.
● Maintains secure, confidential reporting channels (e.g., hotline/grievance mechanisms) for reporting concerns without fear of retaliation.
● Receives, documents, and coordinates investigations into reported compliance, ethical, or regulatory issues in coordination with HR, legal counsel, HIM, and Finance .
● Monitors compliance risks related to billing/coding integrity, medical necessity, provider credentialing, fraud/waste/abuse prevention, vendor relationships, and exclusion screenings .
● Maintains a centralized compliance issue log and provides regular reporting to executive leadership and the Governing Board .
● Directs clinical risk identification, incident analysis, and claims management coordination in conjunction with legal counsel and liability carriers .
● Performs medical record reviews to evaluate potential compensable events (PCEs), documentation defects, and liability exposures .
● Prepares comprehensive risk identification, grievance, and patient safety trend reports for the CEO, Medical Staff committees, and Governing Board .
● Leads multidisciplinary teams through RCAs and FMEAs following adverse patient safety events or identified clinical practice risks .
● Interacts with patients/families during grievance reviews or risk events to diffuse litigious occurrences and support patient satisfaction .
● Coordinates the clinical education and continuing education framework for clinical, auxiliary, and administrative hospital staff .
● Assists department managers in establishing annual clinical competency standards, orientation curricula, and mandatory regulatory in services (e.g., safety, fire, infection control, BLS) .
● Oversees academic affiliation agreements and contracts for educational institutions conducting clinical rotations at the hospital .
● Develops instructional materials, educational tools, and resources regarding quality standards, documentation integrity, and risk reduction practices .
● Architects and maintains the centralized hospital-wide quality and compliance dashboard using standardized metrics and stoplight reporting .
● Performs complex data mining, data validation, and trending across clinical outcomes and regulatory metrics .
● Prepares and presents objective quarterly and annual program evaluations and work plans to the CEO, Quality Committee, and Governing Board .
● Advises executive leadership on emerging regulatory shifts, legislative changes, and strategic risk mitigations .
Minimum Qualifications
Education
● Required: Bachelor’s Degree from an accredited institution in Nursing (BSN), Healthcare Administration, Public Health, or a related healthcare field .
● Preferred: Master’s Degree in Nursing (MSN), Healthcare Administration (MHA), or Business Administration (MBA) .
Licensure & Certifications
● Required: Active, unencumbered Registered Nurse (RN) license in the State of Texas .
● Preferred: Certified Professional in Healthcare Quality (CPHQ), Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Risk Management (CPHRM), or Lean Six Sigma certification .
Experience
● Minimum of five (5) years of clinical experience in an acute care setting .
● Minimum of five (5) years of progressive experience in hospital Quality Management, Regulatory Compliance, or Risk Management .
● Demonstrated experience in Critical Access Hospital (CAH) operations, survey preparation, and board-level presentation .
Physical Demands & Working Conditions
● Physical Effort: Frequent sitting, standing, and walking throughout hospital and clinic settings . Occasional lifting and carrying of supplies, audit binders, or equipment up to 20 pounds .
● Environment: Professional administrative office and clinical care environments . Potential exposure to infectious conditions, clinical equipment, and hazardous materials requiring standard PPE precautions .
● Schedule: Full-time exempt leadership position . May require availability outside standard business hours for urgent regulatory, survey, or risk escalation events .
Join us as we uphold the highest standards of healthcare excellence! This role offers an inspiring environment where your expertise directly impacts patient safety, organizational integrity, and operational success. If you’re ready to lead transformative quality initiatives within a forward-thinking organization committed to excellence in healthcare compliance—apply today!
Pay: $44.38 - $60.34 per hour
Benefits:
- 401(k)
- 401(k) matching
- AD&D insurance
- Dental insurance
- Employee assistance program
- Employee discount
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Prescription drug insurance
- Vision insurance
- Wellness program
Work Location: In person
