Quality and Medical Audit Director (Healthcare Industry Exp) QHC0009

Quality and Medical Audit Director (Healthcare Industry Exp) General Job Information - Job Title: Quality and Medical Audit Director - Department: Quality, Compliance & Medical Governance Role Summary The Quality and Medical Audit Manager is responsible for leading quality assurance, clinical audit, compliance monitoring, and continuous improvement activities across QHC’s healthcare services. The role ensures that clinical and operational practices meet internal standards, regulatory requirements, accreditation expectations, and patient safety objectives. Key Responsibilities 1. Quality Governance & Framework Development - Develop, implement, and maintain quality management frameworks, policies, procedures, and audit tools. - Support the establishment of clinical governance standards across medical, rehabilitation, sports medicine, wellness, and support services. - Ensure quality programs are aligned with organizational objectives, regulatory requirements, and healthcare best practices. - Support leadership in defining quality priorities, improvement plans, and governance reporting requirements. 2. Medical Audit Planning & Execution - Develop annual and periodic medical audit plans based on risk areas, service priorities, regulatory requirements, and leadership direction. - Conduct audits of clinical documentation, patient records, treatment pathways, coding accuracy, medical protocols, and service delivery processes. - Review compliance with clinical guidelines, documentation standards, patient safety practices, consent processes, and care pathways. - Identify audit findings, root causes, gaps, and improvement opportunities. - Prepare clear audit reports with findings, risk ratings, recommendations, and corrective action requirements. 3. Compliance Monitoring & Regulatory Readiness - Monitor adherence to applicable healthcare regulations, licensing requirements, accreditation standards, and internal policies. - Support preparation for internal reviews, external audits, accreditation visits, and regulatory inspections. - Maintain audit evidence, compliance documentation, quality records, and corrective action trackers. - Coordinate with clinical, operational, and administrative teams to ensure readiness and timely response to audit requirements. 4. Patient Safety & Risk Management - Support patient safety programs, incident reporting, risk assessments, and investigation processes. - Analyze incidents, near misses, complaints, and quality indicators to identify recurring risks and system gaps. - Support root cause analysis and development of corrective and preventive actions. - Monitor implementation of risk mitigation plans across service lines. - Escalate significant quality, safety, or compliance risks to leadership. 5. Performance Monitoring & Quality Reporting - Define and track quality KPIs, audit indicators, patient safety measures, compliance scores, and corrective action progress. - Prepare dashboards, reports, and presentations for leadership and governance committees. - Analyze trends in audit findings, incidents, complaints, documentation quality, and clinical outcomes. - Provide actionable insights to improve quality, safety, and operational performance. 6. Continuous Improvement & Corrective Action Management - Lead quality improvement initiatives to enhance patient safety, service consistency, documentation quality, and compliance. - Follow up on corrective and preventive action plans to ensure timely closure and sustainable improvement. - Work with service line leaders to redesign processes, address gaps, and standardize best practices. - Promote a culture of continuous improvement, accountability, and learning across teams. 7. Stakeholder Collaboration & Training - Partner with physicians, therapists, nurses, operations teams, administrative teams, and service line leaders to improve quality performance. - Provide guidance and awareness sessions on quality standards, audit requirements, documentation practices, and compliance expectations. - Support teams in understanding audit findings and implementing corrective actions. - Act as a quality advisor to operational and clinical teams. Key Performance Matrix - Maintain high compliance with clinical, regulatory, accreditation, and internal quality standards. - Deliver annual and periodic medical audit plans on time and with high-quality reporting. - Reduce repeat audit findings through effective corrective and preventive actions. - Improve documentation quality, clinical compliance, and patient safety indicators. - Ensure timely closure of audit findings and corrective action plans. - Strengthen audit readiness across service lines and reduce regulatory or accreditation gaps. - Improve quality reporting accuracy, governance visibility, and leadership decision support. Qualifications - Bachelor’s degree in Medicine, Nursing, Healthcare Administration, Quality Management, Public Health, or related field

Bachelor’s degree in Medicine, Nursing, Healthcare Administration, Quality Management, Public Health, or related field

Quality Governance & Framework Development: Develop, implement, and maintain quality management frameworks, policies, procedures, and audit tools. Support clinical governance standards across medical, rehabilitation, sports medicine, wellness, and support services. Ensure quality programs align with regulatory requirements and healthcare best practices. Define quality priorities, improvement plans, and governance reporting requirements. Medical Audit Planning & Execution: Develop annual and periodic medical audit plans based on risk areas, regulatory requirements, and leadership direction. Conduct audits of clinical documentation, patient records, treatment pathways, coding accuracy, medical protocols, and service delivery processes. Review compliance with clinical guidelines, documentation standards, patient safety practices, consent processes, and care pathways. Identify audit findings, root causes, gaps, and improvement opportunities. Prepare audit reports with findings, risk ratings, recommendations, and corrective actions. Compliance Monitoring & Regulatory Readiness: Monitor adherence to regulations, licensing, accreditation standards, and internal policies. Prepare for internal reviews, external audits, accreditation visits, and inspections. Maintain audit evidence, compliance documentation, quality records, and corrective action trackers. Coordinate with clinical, operational, and administrative teams to ensure readiness and timely response. Patient Safety & Risk Management: Support patient safety programs, incident reporting, risk assessments, and investigation processes. Analyze incidents, near misses, complaints, and quality indicators to identify recurring risks and system gaps. Support root cause analysis and development of corrective and preventive actions. Monitor implementation of risk mitigation plans across service lines. Escalate significant risks to leadership. Performance Monitoring & Quality Reporting: Define and track quality KPIs, audit indicators, patient safety measures, compliance scores, and CAPA progress. Prepare dashboards and reports for leadership and governance Committees. Analyze trends in audit findings, incidents, complaints, documentation quality, and outcomes. Provide actionable insights to improve quality, safety, and performance. Continuous Improvement & Corrective Action Management: Lead quality improvement initiatives to enhance patient safety, service consistency, documentation quality, and compliance. Follow up on CAPA plans to ensure timely closure. Redesign processes with service line leaders, standardize best practices, and promote a culture of continuous improvement. Stakeholder Collaboration & Training: Partner with physicians, therapists, nurses, operations, and service line leaders to improve quality performance. Provide guidance and awareness sessions on quality standards, audit requirements, documentation practices, and compliance expectations. Support teams in understanding audit findings and implementing corrective actions. Act as a quality advisor to operational and clinical teams.