Director of Quality Review & Performance Improvement

Job Summary

The Director of Quality Assurance/UR/PI is responsible for strategic leadership and oversight of all quality-related programs and initiatives across the facility, including Utilization Review (UR), Performance Improvement (PI), Accreditation and Clinical Outcomes. This position collaborates with hospital leadership, medical staff, department managers, and external agencies to promote high-quality, cost-effective, and patient-centered care. The Director interprets clinical data, ensures compliance with applicable regulatory and accreditation standards, leads efforts to optimize resource utilization, and drives continuous performance improvement throughout the hospital.

Essential Functions

Lead the development, execution, and evaluation of quality, UR, and PI programs aligned with organizational goals and regulatory requirements

Oversee utilization review processes to ensure efficient and medically necessary use of healthcare resources

Develop, implement, and monitor hospital-wide performance improvement initiatives using evidence-based practices

Direct internal and external audits, survey readiness, and corrective action planning

Analyze clinical and administrative data to identify trends, outcomes, and opportunities for improvement

Lead or co-lead relevant hospital committees including Quality Council, UR Committee, and PI teams

Act as the subject matter expert on quality, UR, and PI topics for hospital leadership, staff, and the Board of Trustees

Facilitate complaint management and service recovery processes

Manage departmental operations including staffing, budget, and strategic planning

Ensure timely and accurate reporting of quality metrics and regulatory compliance data

Knowledge/Skills/Abilities/Expectations

Expert knowledge of hospital accreditation standards, quality methodologies, and clinical performance metrics

Proficient in data analytics, statistical methods, and quality improvement tools (e.g., PDSA, Lean, Six Sigma)

Effective leadership, communication, and interpersonal skills

Strong organizational skills and ability to manage multiple projects simultaneously

Systems thinking with the ability to lead change across departments

Qualifications

Education

High school diploma or equivalent required

Bachelor’s degree in nursing or a health-related field required

Master’s degree in a health-related field preferred

Licenses/Certifications

Current Registered Nurse license required

Must meet licensure requirements within time frame required by facility policy

Basic Life Support (BLS) required

Advanced Cardiac Life Support (ACLS) preferred

Certified Professional in Healthcare Quality (CPHQ) preferred

Certification in specialty area of practice highly recommended

Experience

Minimum of five years of healthcare experience, including at least three years in progressive leadership roles

Experience in quality management, utilization review, performance improvement, infection prevention, risk management, or accreditation required

Demonstrated success leading hospital or system-level accreditation and performance improvement initiatives strongly preferred.