Director of Clinical Certification - FT - Days

Directors and Executives (Nursing and Non-Nursing) Edinburg, Texas


Position at DHR Health


The Director of Clinical Certification is responsible for leadership oversight in planning, administering, and monitoring all aspects of continuous certification survey readiness and compliance with certification regulatory standards; leads and coordinates certification program initiatives to promote awareness, education, and assures continuous assessment and compliance with all rules, regulations, and standards outlined by the  state, CMS, The Joint Commission, and other agencies as they pertain to program-specific certifications.


  • High School/GED required
  • Bachelor's Degree in Nursing required; Master's degree preferred
  • Registered Nurse with current Texas or multistate compact licensure required
  • Excellent customer service skills
  • Computer skills required with knowledge of Microsoft Office Suite
  • Good written and verbal communication skills required
  • Bilingual – English/Spanish preferred



  • Two years’ experience with quality and process improvement methodologies, statistical analysis, and database management preferred
  • A minimum of two years’ experience in an influential role within a hospital or health care organization
  • Strong knowledge of CMS Conditions of Participation, Federal and State regulations, and The Joint Commission accreditation and certification standards
  • Current working knowledge of ethical, regulatory, and accreditation and certification requirements and ability to interpret into sound clinical practice and policy
  • Demonstrated strong people skills, oral and written communication skills to effectively deliver presentations, and interpersonal skills necessary to establish and maintain effective working relationships across the Health System
  • Demonstrated ability to problem solve, think critically and creatively, and provide leadership through a consultative role



  • Promotes the facility mission, vision, and values by effectively communicating them to others
  • Considers the mission, vision, and values in developing services, standards, and practices
  • Guides the organization by assessing outcomes and compliance to each program standard and facilitates the development of action plans when gaps are identified and promotes participation by all levels of staff
  • Engages key stakeholders while providing input into the program development, implementation, and monitoring of planned improvements to ensure alignment with regulations and standards
  • Collaborates with relevant cross-functional teams to ensure systems and practices are updated timely and enhance the patient experience to drive better patient outcomes
  • Tracks progress on action plans to ensure accountability within the established time frame
  • Participates in ongoing assessment activities in partnership with the workflow owners and other stakeholders
  • Applies appropriate quality improvement tools and methodologies to performance and process improvement activities
  • Assists in the development of dashboards and scorecards to show internal data as well as benchmark comparisons, communicates results and recommendations, and manages the dissemination of standing and special reports
  • Conducts informal and formal training to stakeholders on an ongoing basis and as needs are identified
  • Escalates improvement plans for further review, analysis, and development, if a plan does not meet the desired outcomes
  • Manages planned and unannounced survey processes related to assigned accreditation and certification programs and facilitates the development and monitoring of action plans for findings
  • Manages, coaches, and mentors staff to improve engagement and development
  • Other duties as assigned