Director of Quality, Accreditation and Compliance

Posting Summary Logo Posting Number STA00329PO26 Job Family Audit, Compliance and Risk Management Job Function Compliance USC Market Title Director Quality, Accreditation & Compliance Link to USC Market Title https://uscjobs.sc.edu/titles/206100 Job Level E0 - Directors and Executives Business Title (Internal Title) Director of Quality, Accreditation and Compliance Campus Columbia Work County Richland College/Division Neurological Critical Care Hospital Department NCCH Neurological Hospital SCHHS State Pay Range Unclassified USC Market Range MRO - $135,866 $173,229 $210,592 Anticipated Hiring Range Salary commensurate with qualifications Location of Vacancy Part/Full Time Full Time Hours per Week 37.5 Work Schedule Standard working schedule: 8:30am - 5:00pm Must be willing to work a flexible schedule to meet the needs of the department. Basis 12 months Job Search Category Health and Human Services About USC About University of South Carolina From the Upstate to the Lowcountry, the University of South Carolina system is transforming the lives of South Carolinians through the impact of our eight institutions and 20 locations throughout the state. More than 50,000 students are enrolled at one of eight institutions, including the research campus in Columbia and comprehensive four-year universities in Aiken, Upstate and Beaufort. In addition, our Palmetto College campuses in Salkehatchie, Union, Lancaster and Sumter enable students to earn associate or bachelor's degrees through a combination of in-person, online or blended learning. All of our system institutions place strong emphasis on service - helping to build healthier, more educated communities in South Carolina and beyond. Veterans' Preference Statement The University of South Carolina is committed to equal opportunity and proudly values the skills and experience military veterans bring to our workforce. Across South Carolina, we are making veterans a priority for employment and recognize their vital contributions to our state and our communities. Benefits for FTE Positions The University of South Carolina (USC), through the State of SC and Public Employee Benefit Authority (PEBA), offers employees a valuable benefits package, including health and life insurance, generous paid leave and retirement programs. To learn more about USC benefits, access the "Working at USC" section on the Applicant Portal at https://uscjobs.sc.edu. Research Grant or Time-limited positions may be eligible for all, some, or no benefits, based on the grant or project funding. Position Description Advertised Job Summary The USC Neurological Hospital is seeking to hire a Director of Quality, Accreditation and Compliance to join our team. The Director of Quality, Accreditation and Compliance provides strategic leadership and operational oversight for the hospital's quality management, patient safety, regulatory compliance and accreditation programs. This role is accountable for ensuring safe, effective, and patient-centered care through continuous performance improvement, regulatory readiness, and accreditation compliance. The Director leads organization-wide initiatives that strengthen regulatory compliance, reduce organizational exposure, and enhance operational reliability while promoting a culture of excellence, transparency, and Just Culture. Working collaboratively with clinical and administrative leaders, this position drives the development, implementation, and monitoring of quality systems, policies, and performance measures to ensure alignment with organizational goals, regulatory requirements, and national best practices. Job Related Minimum Required Education and Experience Requires a bachelor's degree in a job related field and at least 8 years of job related experience, including some prior management experience. Required Certification, Licensure/Other Credentials Professional certification in quality, safety, infection prevention, or process improvement (e.g., CPHQ, CPPS, CIC, CQM). Preferred Qualifications Clinical Degree strongly preferred or master's degree in healthcare administration, Nursing, or a related field Minimum of ten (10) years of progressive leadership experience in acute care quality management, quality assurance, risk management, or regulatory compliance. Six Sigma Green Belt or Black Belt and/or Project Management Professional (PMP) certification. Demonstrated experience leading large-scale performance improvement initiatives within complex healthcare organizations. Extensive knowledge of hospital clinical operations, patient safety principles, infection prevention, risk management, and regulatory requirements. Knowledge/Skills/Abilities Proven ability to build strong internal and external relationships and work effectively across multidisciplinary teams. Strategic thinker with the ability to develop and execute short- and long-term quality and safety improvement plans. Demonstrated success leading organizational change through influence rather than authority. Strong knowledge of healthcare regulations, accreditation standards, improvement methodologies, payer programs, and emerging healthcare trends. Ability to lead through uncertainty, establish Just Culture principles, and create psychological safety. Expertise in performance improvement methodologies and tools, with the ability to manage multiple projects simultaneously while coaching others. Strong analytical, communication, and presentation skills. Proficiency in Microsoft Word, Excel, PowerPoint, Visio, and database systems. Job Duties Job Duty Quality Management & Performance Improvement: Lead the design, implementation, and oversight of quality management and performance improvement programs across hospital operations and affiliated clinical programs, ensuring alignment with national, state, and local standards. Develop and monitor quality initiatives focused on reducing clinical variation, preventing harm, improving patient outcomes, and sustaining accreditation compliance (e.g., CMS, CIHQ). Oversee the collection, analysis, validation, and reporting of core measures, electronic clinical quality measures (eCQMs), Meaningful Use metrics, and IQR/OQR programs. Establish and maintain quality dashboards and analytic tools to monitor performance, identify trends, and guide data-driven decision making. Partner with clinical and operational leaders to implement evidence-based practices and sustain measurable improvements in care delivery. Essential Function Yes Percentage of Time 20 Job Duty Patient Safety & Quality Improvement: Provide leadership for patient safety to proactively identify, prevent, and mitigate clinical and operational risk. Lead and/or oversee root cause analyses (RCAs), failure mode and effects analyses (FMEAs), and other safety event investigations. Ensure timely development, implementation, and monitoring of corrective action plans resulting from adverse events, near misses, and safety concerns. Promote and model a Just Culture framework that supports open reporting, learning from error, and psychological safety. Foster a non-punitive environment where staff are encouraged to speak up, escalate concerns, and engage in meaningful quality improvement. Essential Function Yes Percentage of Time 20 Job Duty Regulatory Compliance & Accreditation: Provide enterprise leadership oversight for regulatory compliance and continuous accreditation readiness across all departments. Serve as the organizational lead for accreditation surveys, regulatory audits, and site visits, including coordination of preparation activities and follow-up actions. Ensure timely, accurate, and complete submission of all required regulatory and quality reporting. Monitor regulatory changes and emerging standards, advising leadership on compliance risks and strategic response. Essential Function Yes Percentage of Time 20 Job Duty Data Analytics, Reporting & Governance: Lead enterprise quality data governance, including metric selection, performance targets, and standardization of reporting. Analyze clinical and operational data to identify trends, gaps, and opportunities for improvement. Prepare and present quality, safety, and compliance reports to senior leadership, medical staff, and the executive leadership. Translate complex data into clear, actionable insights that support operational improvement and strategic decision making. Essential Function Yes Percentage of Time 20 Job Duty Leadership & Collaboration: Build strong partnerships with physicians, nursing leaders, department managers, and executive leadership to advance quality and safety goals. Influence change across disciplines through collaboration, coaching, and effective communication. Lead, mentor, and develop quality and risk staff, fostering professional growth and accountability. Support organizational initiatives related to safety culture, health equity, patient experience, and population health, as applicable. Essential Function Yes Percentage of Time 20 Position Attributes Employees in Safety-Sensitive or Security-Sensitive positions will be subject to pre-employment and post-employment drug testing in accordance with University policy HR 1.95 Drug and Alcohol Testing. Safety Sensitive or Security Sensitive No Hazardous weather category Non-Essential Posting Detail Information Number of Vacancies 1 Desired Start Date Job Open Date 05/11/2026 Job Close Date 06/01/2026 Open Until Filled No Special Instructions to Applicant Positions are advertised for a minimum of five (5) business days on our job website. After five (5) business days, positions can be closed at the discretion of the department at any time. This employment site is updated on a regular basis. The length of the recruitment and screening process may vary from position to position, depending upon a variety of factors. Should review of your qualifications result in a decision to pursue your candidacy, you will be contacted by phone or email. We are only accepting applications submitted by June 1, 2026. The University of South Carolina offers a valuable benefits package including but not limited to Health and Life Insurance Retirement Programs Paid Tuition Dependent Scholarships Annual Leave Sick Leave 13 Paid Holidays (including an extended December holiday) Paid Parental Leave Professional Development Opportunities Click here to learn more about why you should work at USC. Quicklink for Posting https://uscjobs.sc.edu/postings/206138 EEO Statement The University of South Carolina does not discriminate in educational or employment opportunities or decisions for qualified persons on the basis of age, ancestry, citizenship status, color, disability, ethnicity, familial status, gender (including transgender), gender identity or expression, genetic information, HIV/AIDs status, military status, national origin, pregnancy (false pregnancy, termination of pregnancy, childbirth, recovery therefrom or related medical conditions, breastfeeding), race, religion (including religious dress and grooming practices), sex, sexual orientation, veteran status, or any other bases under federal, state, local law, or regulations. Supplemental Questions Required fields are indicated with an asterisk (*). * Do you have at least a bachelor's degree in a job related field and at least 8 years of job related experience, including some prior management experience? Yes No Do you have a professional certification in quality, safety, infection prevention, or process improvement (e.g., CPHQ, CPPS, CIC, CQM)? Yes No Applicant Documents Required Documents Cover Letter Resume List of References and Contact Information Optional Documents