HCA, Hospital Corporation of America Quality Compliance Manager in McAllen, Texas

In collaboration with the Director of QM, formulates a comprehensive program for continuous education, monitoring and assessment of patient care services to support the organizations performance improvement program. Maintain centralized records of compliance review activities to ensure ready access for review and follow-up. Assists with the coordination of regulatory surveys, in particular, the Joint Commission survey. Assists with the preparation of summarized reports of compliance review activities to the Board of Trustees, Hospital Administration, the Medical staff and appropriate committees on a regular basis. Serves as a resource person for accomplishment of compliance activities. Assists with the development of operational standards relevant to compliance improvement wit dissemination of these standards to Department Directors as appropriate.

Coordinates and supervises accreditation survey (e.g., TJC, CMS/TDH, DHHS/Medicaid, and OSHA) audits for the facility.
Collaborates with clinicians and other staff in developing and implementing processes to comply with regulatory standards. No direct patient care functions are provided by this position. Conducts retrospective chart review for the purpose of identifying opportunities for improvement in patient care and with federal and/or accrediting agency standards. Collaborates with clinicians and other staff in developing and implementing processes to drive improvement.

Develops and maintains excellent knowledge of policies and procedures related to federal and/or accrediting agency

Experience in acute healthcare and working knowledge in acute care hospital regulatory compliance (Joint Commission, CMS, TDH, OSHA, etc). Experience with data management including aggregation, analysis and display utilizing process improvement tools. Prefer advanced college degree and/or RN/LVN license


Requires basic understanding and ability necessary to:

  • Exercise judgment within the guidelines of medical plan or care, department policy and licensure practice acts.

  • Apply regulatory standards to design and re-design of processes utilizing process improvement tools

  • Apply principles of data management

  • Facilitate problem-solving process and conflict resolution

  • Strong interpersonal communication skills in both written and verbal format.

  • Strong computer skills

Title: Quality Compliance Manager

Location: Texas-McAllen-Rio Grande Regional Hospital

Requisition ID: 00372-5795