Director of Quality and Accreditation | RN Required | Community Hospital | Georgia

Competitive Compensation | Comprehensive Benefits | Relocation Assistance

Qualified Quality and Patient Safety Clinical Managers interested in progressing into a broader leadership capacity are invited to apply.

Lead Quality, Performance Improvement, and Accreditation efforts for a respected 100‑bed community hospital in Georgia. This environment offers a strong sense of connection, community, and quality of life, along with exceptional visibility to senior leadership. It’s an outstanding opportunity for an experienced RN leader who is passionate about Quality outcomes, regulatory excellence, patient safety, and organizational performance improvement.

As the hospital’s primary leader for Quality Management and Accreditation, this Director will partner closely with executive leadership, medical staff, department directors, and frontline teams to drive a culture of continuous improvement. The role oversees Quality initiatives, regulatory readiness, performance metrics, accreditation activities, peer review processes, and organizational compliance with federal and state Quality standards.
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The surrounding community offers a high quality of life, exceptional outdoor recreation, and the opportunity to make a meaningful impact within a close-knit healthcare environment. This setting is ideal for leaders seeking executive visibility, broad responsibilities, and the ability to influence organizational outcomes.

Georgia

• 100-bed TJC Accredited Acute Care Community Hospital
• Lead the development, implementation, evaluation, and ongoing advancement of the organization's Quality Improvement program
• Direct all accreditation and regulatory readiness activities, ensuring continuous compliance with state, federal, and accreditation requirements
• Serve as the organizational subject matter expert for Quality, patient safety, performance improvement, and regulatory standards
• Coordinate Quality reporting activities for executive leadership, medical staff committees, and governing bodies
• Oversee clinical Quality databases, performance metrics, and outcome reporting systems
• Lead data collection, analysis, trending, benchmarking, and performance improvement initiatives across the organization
• Partner with clinical and operational leaders to identify improvement opportunities and develop measurable action plans
• Coordinate peer review activities and support Medical Staff and Quality committees in collaboration with physician leadership
• Ensure accurate and timely submission of mandatory Quality and outcome reporting to CMS, state agencies, and accrediting organizations
• Facilitate Quality education programs for hospital staff, leadership, and medical staff
• Serve as an internal consultant for departments seeking guidance with Quality improvement initiatives and process redesign
• Support organizational readiness for surveys, inspections, and accreditation activities while promoting continuous survey preparedness
• Collaborate with Compliance and Risk leadership regarding regulatory concerns, investigations, education, and readiness activities
• Champion a culture focused on patient safety, accountability, transparency, and clinical excellence

• RN required
• Bachelor's degree in Nursing, Healthcare Administration, or related field required, Master's degree preferred
• Minimum of 5 years of healthcare Quality leadership experience required
• Previous hospital-based Quality, Performance Improvement, Accreditation, or Patient Safety experience required
• Certified Professional in Healthcare Quality (CPHQ) preferred
• Lean Six Sigma training or certification preferred
• Strong knowledge of CMS, accreditation standards, core measures, Quality reporting, and regulatory requirements
• Experience with data analysis, performance improvement methodologies, and Quality dashboards required
• Knowledge of medical staff processes, peer review, credentialing, and Quality committee structures preferred
• Demonstrated ability to influence change across multiple departments and organizational levels
• Exceptional communication, leadership, presentation, and relationship-building skills

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