Director of Quality and Risk Management

Provide executive oversight for the hospital's Quality Assessment and Performance Improvement (QAPI) and Risk Management programs. Lead hospital-wide performance improvement initiatives focused on patient safety and clinical outcomes.

Lead regulatory readiness for CMS and accreditation surveys, ensuring adherence to federal, state, and accrediting-body standards. Chair the Quality and Patient Safety Committee, report metrics to executive leadership and the governing board, and direct incident reporting, root cause analysis, and risk mitigation strategies.

Ensured organizational compliance with HRSA, OIG, CMS, and OSHA regulations. Conducted patient chart audits and oversaw continuous quality improvement indicators and documentation standards.

Led internal compliance review and monitoring activities. Presented policies to the Board of Directors for approval and supported the organization in maintaining strong regulatory and quality practices.

Led facility-level regulatory and accreditation compliance initiatives involving TJC, CMS, and OSHA requirements. Implemented the Quality and Patient Safety Plan to support safe, compliant care delivery.

Managed data collection and quality reporting processes to monitor performance improvement activities. Supervised two direct reports and supported quality and patient safety operations across the facility.

Doctor of Public Health program in Health Management & Policy; listed as expected completion in May 2025.

Master of Public Health.

Graduate certificate in Health Data Analytics.

Graduate certificate in Epidemiology.