Alta Newport Hospital, Inc. Job - 35036325 | CareerArc
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Company: Alta Newport Hospital, Inc.
Location: Tustin, CA
Career Level: Director
Industries: Hospitals, Health Care


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Current employees can apply directly through the Internal Careers Center online for Prospect Medical job openings in California. For a streamlined application process, all you need is your four-digit employee ID number and a digital copy of your résumé handy before you apply.


Director - Quality (FRMC)

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Director, Quality serves as a regulatory accreditation expert and ensures ongoing compliance with federal/state regulatory expectations and accrediting organization requirements.  Develops and leads the execution of the hospital's Quality Assurance/Performance Improvement (QAPI) program to include working with the leadership team to proactively identify opportunities for improvement and implement mitigation strategies on an ongoing basis.  The Director, Quality also ensures that an evaluation of the hospital's Quality Assurance/Performance Improvement (QAPI) program occurs on an annual basis. Develops and leads the execution of the hospital's ongoing survey readiness strategy to include internal readiness audits, written reports of out of compliance findings, and oversight of action plans to mitigate findings under the direction of the Hospital CEO and Corporate Vice President of Quality/Patient Safety. Reviews all action plans, 2567's and Measures of Success prior to submission to any regulatory or accreditation organization and will work with the hospital leadership to ensure initial compliance and ongoing sustainment as directed.  Acts as a resource for CMS regulatory and outcomes monitoring programs; for federal reporting system(s); and will create, distribute, and implement tools and other resources to the facilities.  Serves as a subject matter expert in federal/state regulations, accreditation standards and CMS Pay-for-Performance programs.

Job Responsibilities/Duties


  • Serves as a regulatory and accreditation subject matter expert and ensures ongoing compliance with federal/state regulatory expectations and accrediting organization requirements.
  • Ensures department is meeting established goals and objectives and performance improvement initiatives in support of overall goals of the PMH Quality Assurance/ Performance Improvement program.  Establishes and maintains appropriate monitoring and control systems to ensure goals and objectives are achieved.
  • Provides oversight in the development, implementation, and evaluation of the quality, patient safety, and infection prevention programs at the hospitals. Oversees the Quality Coordinator to collect and analyze data; identify trends; prioritize, recommend, and provide oversight for improvements; decrease duplication, and ensure any other relevant regulatory or reporting organizations compliance.   Oversees the Infection Control Manager to direct the management, planning, development, implementation, evaluation/continuous improvement of the infection prevention and control program across entire care continuum.
  • Maintains current knowledge of the Joint Commission, State, and any other relevant regulatory or reporting organizations' standards on quality indicators and certification processes. Supports accreditation process including triennial surveys, random unannounced surveys, and complaint surveys.  Maintains current knowledge of CMS Pay-for-Performance programs and works with the hospital's leadership to ensure that the organization's systems and processes are aligned with evidence based practices that attribute to quality care and increased value based purchasing incentives.
  • Develops and implements facility continual survey readiness plan; conducts internal audit process to measure survey readiness; provides survey rapid response assistance as needed; assists with survey response development; oversees action plan compliance.  Knowledge of accreditations, CDPH/CMS surveys, Medicare Quality-Based Payment Reform (VBP, HAI, MRRP, MSPB) QIO interaction, Clarity report mitigation, RCA conduction, work with Medical Staff on Peer Review Process.

Minimum Education: Bachelor's degree in relevant healthcare clinical area required. MN/MSN, MPH, MHA or MBA or related area preferred.

Minimum Experience: Seven (7) years of healthcare experience with two (2) years of experience in leading Quality required. Demonstrates ability to develop and lead employees at all levels including key leadership; demonstrates ability to get things done through influence rather than direct management control. Excellent verbal and written communication skills. Quality Measure Performance Improvement experience required. Computer Literacy and Proficiency in MS Office, specifically Word and Excel. Ability to maintain flexibility and work well in a fast paced, constantly changing environment. Ability to establish and maintain effective working relationships across the organization. Experience within a multi-site, multi-state healthcare system preferred.

Req. Certification/Licensure: CPHQ, CHCQM or equivalent within one (1) year of employment required. Registered Nurse or other clinical license preferred.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance
How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law:

Keywords: Risk Management, Quality, RM, Acute Care Hospital, Quality & Risk, Acute Care Hospital


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