Corporate Quality Manager

Exalt Health, an acute rehabilitation hospital, provides an intensive rehabilitation program, and admitted patients must be able to tolerate three hours of intense rehabilitation services per day. Focused on caring for patients with complex rehabilitative needs such as stroke, spinal cord injury, brain injury, head trauma, medically debilitation conditions, neurological disorders, cardio-pulmonary amputations, orthopedic injuries, and multiple major traumas.

Position Summary

The Corporate Quality Manager (RN) is responsible for driving and standardizing quality and compliance initiatives across all Exalt Health Rehabilitation Hospital facilities. This role ensures system-wide adherence to clinical standards, regulatory requirements (including CMS and state licensure), and accreditation guidelines (CIHQ). Reporting directly to the Chief Compliance Officer, the Corporate Quality Manager serves as a primary resource for hospital-level Quality Directors and clinical leadership, providing expert consultation on quality improvement, policy interpretation, investigations, and medical record integrity.

Key Responsibilities

• Accreditation and Regulatory Oversight:
  • Oversee and coordinate system-wide preparedness for and response to regulatory surveys from agencies including CMS (Centers for Medicare & Medicaid Services), state licensing bodies, and the CIHQ (Center for Improvement in Healthcare Quality).
  • Maintain current knowledge of all applicable laws, regulations, and accreditation standards relevant to inpatient rehabilitation facilities (IRFs) and ensure their consistent implementation across the organization.
  • Direct the corporate quality calendar, tracking critical compliance deadlines, survey cycles, and mandatory reporting requirements.
• Quality Program Management:
  • Work directly with hospital-level Directors of Quality to implement, standardize, and monitor best practices in patient care, risk management, and quality improvement programs.
  • Analyze quality performance data, identify trends, and collaborate with hospital leadership to develop and execute targeted corrective action plans (CAPs) for sustained improvement.
  • Develop and facilitate quality training and educational programs for clinical and administrative staff.
• Clinical Consulting and Support:
  • Serve as a clinical consultant to hospital leadership, providing expert interpretation of organizational policies and procedures as they relate to patient care and quality standards.
  • Provide guidance on clinical investigations, including patient safety events, potential regulatory non-compliance, and sentinel events.
  • Provide oversight and guidance on medical record management, focusing on documentation integrity, completeness, and adherence to legal and regulatory standards.

Qualifications

• Education: Bachelor of Science in Nursing (BSN) required. Master’s degree in Healthcare Administration, Nursing, or a related field is preferred.
• Licensure: Current, active Registered Nurse (RN) license in the state where the corporate office is located, with the ability to obtain licensure in other states as required by business needs.
• Experience:
  • Minimum of five (5) years of progressive experience in clinical healthcare, with at least three (3) years in a dedicated quality, compliance, or risk management role within a hospital or healthcare system.
  • Demonstrated expertise in accreditation standards (CIHQ, TJC, or DNV) and federal/state regulations, particularly those governing inpatient rehabilitation facilities (IRFs).
  • Experience working with regulatory bodies (CMS, state health departments) and managing hospital surveys.
• Skills & Attributes:
  • Strong analytical, problem-solving, and data interpretation skills.
  • Exceptional written and verbal communication skills for effective interaction with all levels of staff, from frontline nurses to executive leadership.
  • Proven ability to lead, influence, and manage projects across multiple facilities without direct reporting authority.
  • Proficiency in quality improvement methodologies (e.g., Lean, Six Sigma) is a plus.