What are the responsibilities and job description for the Director of Quality Review & Performance Improvement position at WSG Energy Services?
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.
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.
