Job Description

Job Summary

The Clinical Quality & Regulatory Consultant partners with skilled nursing facilities, long-term care organizations, and post-acute providers to improve quality, strengthen compliance, and prepare for regulatory surveys. This role combines consultative support, staff education, and regulatory expertise to guide facilities in achieving sustainable improvements. The consultant supports leadership and frontline staff by providing mock surveys, QAPI coaching, policy and process reviews, risk analysis, and high-risk incident response, with a focus on building confidence and compliance culture.

Essential Duties and Responsibilities

1. Conduct mock surveys using CMS/state protocols, providing constructive feedback, staff interviews, and real-time coaching.
2. Perform observations and record reviews (care plans, QAPI documentation, policies, incident reports) to identify compliance risks and teach staff how surveyors evaluate facilities.
3. Lead educational debriefings and staff in-services, celebrating strengths and addressing compliance gaps in plain language.
4. Support QAPI program development, including root cause analysis (RCA), data tracking, corrective action plans, and follow-up reviews.
5. Provide consultative guidance on clinical quality improvement, including infection control, falls prevention, wound care, medication management, and other high-risk areas.
6. Assist with policy and procedure development, review, and alignment with regulatory requirements.
7. Conduct risk assessments and incident reviews, supporting facilities in developing sustainable corrective strategies.
8. Partner with facility leadership on process improvement initiatives to reduce deficiencies, improve outcomes, and strengthen compliance culture.
9. Deliver written reports and recommendations that are practical, measurable, and sustainable.
10. Stay current on CMS regulations, QSO memos, and state survey protocols, bringing timely updates and best practices to clients.

Knowledge, Skills & Abilities

1. Proficient computer skills (MS Word, Excel, PowerPoint).
2. Excellent oral, written, and customer service-oriented communication skills.
3. Excellent and demonstrated critical thinking ability.
4. Excellent organizational skills with the ability to respond to and coordinate multiple activities simultaneously under short time frames.
5. Customer service-oriented when working with internal and external customers.
6. Consultative Coaching: Guides facilities through compliance in a positive, educational manner.
7. Regulatory Expertise: Deep knowledge of CMS/state requirements and best practices.
8. Quality & Risk Management: Skilled in identifying risks and building sustainable improvement strategies.
9. Communication: Effective trainer and communicator across all staff levels.
10. Process Improvement: Uses RCA, audits, and QAPI to drive measurable outcomes.

Education, Experience, & Licensing Requirements

Education

1. High School diploma or equivalent required. Bachelor’s degree in nursing, Healthcare Administration, or a related field preferred.
2. Registered nurse license in good standing required.

Experience

1. Prior experience as a State Surveyor, DON, Administrator, or Consultant required.
2. Minimum of 5 years of experience in long-term care compliance, survey process, or quality improvement.
3. RN, LNHA, or equivalent clinical/administrative background with survey and compliance experience.
4. Strong educator and coach who can simplify regulations for frontline staff.
5. Excellent communication and interpersonal skills; able to guide without intimidation.
6. Skilled in root cause analysis (RCA), QAPI coaching, and staff development.
7. In-depth knowledge of CMS F-Tags, QAPI, infection prevention, behavioral health requirements, and regulatory compliance.
8. Strong educator and facilitator able to train, coach, and mentor staff at all levels.
9. Excellent skills in risk analysis, RCA, and process improvement.
10. Ability to provide objective, constructive feedback that supports growth and improvement.

Travel Requirements

1. This position is home office-based, with the expectation that the employee will work remotely from a dedicated home office. Travel of up to 50% is required to meet with clients and potential customers, attend industry events, and participate in in-person meetings or corporate functions as needed, including occasional visits to the Memphis corporate office for event preparation, attendance, and follow-up.
2. Flexible working hours, including evenings and weekends, may be required based on customer needs and business demands.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

1. Employee will constantly communicate with others regarding employment-related information or instruction and must be able to exchange accurate information in these situations.
2. This role requires constant use of standard office equipment, such as computers and telephones, to receive and share information.
3. Employee must be able to read and interpret information displayed on a computer screen.
4. Employee must be able to remain in a stationary position for extended periods of time.
5. This role occasionally requires the employee to lift light objects up to 25 pounds.

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