About The Role

Nutex Health | Quality Manager The Quality Manager within the Compliance Department is responsible for leading, coordinating, and supporting system-wide quality and compliance initiatives across all healthcare facilities. This role ensures that quality programs are effectively implemented, continuously monitored, and aligned with regulatory requirements, accreditation standards, and organizational goals.

The Quality Manager works closely with Compliance, Risk Management, Nursing Leadership, Medical Staff, Operations, and Facility Leadership to monitor performance, identify improvement opportunities, and ensure safe, high-quality patient care environments.

This position plays a key role in ensuring that quality metrics, regulatory readiness, patient safety initiatives, and performance improvement activities are consistently executed across the organization.

ESSENTIAL RESPONSIBILITIES

Quality Program Oversight

Lead and support system-wide quality initiatives within the Compliance Department.
Develop, implement, and maintain quality monitoring programs across all facilities.
Ensure alignment of quality programs with CMS requirements, accreditation standards, and organizational policies.
Monitor effectiveness of quality initiatives and recommend improvements based on findings and trends.
Support integration of quality initiatives into daily clinical and operational workflows.

Performance Improvement & Data Analysis

Collect, analyze, and interpret quality and performance data across facilities.
Identify trends, gaps, and opportunities for improvement in patient care and operational processes.
Develop and maintain quality dashboards, reports, and performance scorecards.
Present findings and recommendations to Compliance leadership, executive teams, and facility leadership.
Support continuous improvement initiatives and evidence-based decision-making.

Regulatory & Accreditation Compliance Support

Support survey readiness for regulatory agencies and accreditation organizations.
Assist facilities in responding to deficiencies, corrective actions, and follow-up requirements.
Ensure quality programs align with CMS Conditions of Participation and applicable state regulations.
Maintain awareness of regulatory updates and translate requirements into operational improvements.
Support documentation and reporting required for audits and surveys.

Patient Safety & Risk Collaboration

Partner with Risk Management and Compliance teams to identify and address patient safety concerns.
Assist in investigation of adverse events, near misses, and quality-related incidents.
Participate in root cause analysis (RCA), failure mode and effects analysis (FMEA), and other improvement methodologies.
Support development and implementation of corrective action plans.
Promote a culture of safety and accountability across all facilities.

Facility Support & Education

Provide guidance and education to facility leadership and staff on quality programs, expectations, and performance standards.
Assist in training staff on quality metrics, reporting tools, and improvement methodologies.
Support facilities in understanding and meeting quality benchmarks and regulatory expectations.
Serve as a resource for questions related to quality reporting, compliance, and performance improvement initiatives.

Collaboration & Program Integration

Work closely with Compliance, Risk Management, Clinical Leadership, Operations, and Medical Staff leadership.
Ensure alignment between quality programs and other organizational initiatives.
Participate in system-wide committees, quality meetings, and leadership discussions.
Support integration of quality initiatives across multiple facilities and service lines.

Reporting & Documentation

Maintain accurate and timely quality reports, dashboards, and performance tracking tools.
Ensure documentation is complete and audit-ready for regulatory review.
Track corrective action plans and monitor completion and effectiveness.
Provide regular updates to Compliance leadership and executive teams.

QUALIFICATIONS

Education

Bachelor’s degree in Nursing, Healthcare Administration, Public Health, Business, or related field required.
Master’s degree preferred.

Experience

Minimum 5 years of experience in healthcare quality, compliance, risk management, or hospital operations required.
Experience in a multi-facility healthcare system strongly preferred.
Experience with performance improvement, regulatory compliance, or accreditation readiness required.
Leadership or project management experience preferred.

Preferred Certifications

Certified Professional in Healthcare Quality (CPHQ)
Certified Professional in Patient Safety (CPPS)
Certified in Healthcare Compliance (CHC)
Lean Six Sigma Certification

Knowledge, Skills, and Abilities

Strong understanding of healthcare quality standards, regulatory requirements, and accreditation expectations.
Ability to analyze complex data and translate findings into actionable improvement plans.
Strong knowledge of performance improvement methodologies (RCA, FMEA, PDSA).
Excellent communication, presentation, and leadership skills.
Ability to collaborate across clinical, operational, and administrative departments.
Strong organizational skills and attention to detail.
Ability to manage multiple priorities in a fast-paced, multi-site environment.