Job Description

Roles & 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.

Desired Candidate Profile

Qualifications

• Bachelor s degree in Medicine, Nursing, Healthcare Administration, Quality Management, Public Health, or related field.
• Master s degree in Healthcare Quality, Healthcare Administration, Public Health, or related discipline is preferred.
• 8 12 years of experience in healthcare quality, clinical audit, medical audit, patient safety, compliance, or accreditation.
• Experience in hospitals, clinics, rehabilitation centers, sports medicine, or integrated healthcare environments is preferred.
• Professional certification in healthcare quality, patient safety, audit, or risk management is preferred, such as CPHQ, ISO auditor, or equivalent.