COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit

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   Current UPMC employees must apply in HR Direct

Director of Quality, Patient Safety, and Compliance

  • Job ID: 174323367
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: Primarily daylight with 24/7 coverage as needed
  • Shift: Day Job
  • Facility: UPMC Jameson
  • Department: Quality - Risk Mgmt
  • Location: 1211 Wilmington Avenue, New Castle PA 16105
  • Union Position: No
  • Salary Range: $0 / hour


UPMC Jameson and UPMC Horizon is currently looking for a Director of Quality, Patient Safety, and Compliance to join the team! This position will have quality, patient safety, and compliance oversight of UPMC Jameson in New Castle, PA, UPMC Horizon- Shenango Valley in Farrell, PA, and UPMC Horizon- Greenville in Greenville, PA. The individual selected for this role will primarily work Monday- Friday day shift but will maintain 24/7 department responsibility as well as rotating administrative call across the 3 campuses.

Provides administrative leadership and overall direction to the Quality, Patient Safety, Infection Control, Regulatory, Compliance, HIPAA & Privacy, Physician Peer Review, Orthopedic Center of Excellence and Care Management and Social Work functions.


  • Provides administrative leadership and overall direction to the Quality, Patient Safety, Infection Control, Regulatory Compliance, HIPAA & Privacy, Physician Peer Review, Orthopedic Center of Excellence and Care Management and Social Work functions.
  • Serve as the senior internal consulting resource for clinical measurement, analysis and reporting.
  • Develop, implement, or utilize appropriate existing system data management capability that supports clinical program initiatives, decision support and regulatory compliance.
  • Demonstrate a collaborative leadership role in the External Regulatory Survey process, to ensure compliance and continual readiness for accreditation and licensure surveys.
  • Provide leadership and preparation for Regulatory Compliance including DOH Licensure and Joint Commission Accreditation Surveys.
  • Serve as the local leadership contact and resource for the UPMC Office of Ethics, Compliance, and audit to ensure the facility adheres to the federal requirements of a compliance program. Responsibilities include but are not limited to: Physician Sunshine Act (open payments), Compliance Line responses, conducting compliance audits, education, and action plans.
  • Serve as the local HIPAA and Privacy leadership contact, in conjunction with local privacy team, for the UPMC Office of Patient and Consumer Privacy (OPCP). Oversite of all local HIPAA investigations, maintaining an account of disclosures to ensure accurate reporting to the Office of Civil Rights.
  • Demonstrate an interactive leadership style that influences thinking and reshapes the quality environment.
  • Serves as the local leadership contact, in conjunction with Patient Safety staff, for the UPMC Risk Management department and collaborates as such.
  • Provide administrative oversight for Infection Control including surveillance, data collection, education, and collaboration to reduce HAI's.
  • Provide collaborative leadership on a consistent basis that smooth the interface points within the complex matrix environment that includes UPMC, employed physicians, private practice, and multiple clinical sites.
  • Provide collaborative oversite of the physician peer review process to ensure compliance with the Ongoing Professional Practice Evaluation process and adherence to UPMC Passavant Hospital Bylaws and Professionalism Policies.
  • Effectively participate and engage in activities to support and achieve organizational strategic goals including an analysis of quality programs and patient care outcomes.
  • Serves as Facility Contact for PHC4 and PHCQA.
  • Manage all human and financial aspects of the department to assure that standards for quality and cost effectiveness are met. Prepare annual man-hours; expense and capital budget for responsible cost centers based on an analysis of needs of patients, clinical programs, staff and physicians.
  • Works collaboratively with CQSI to ensure current and future obligations are met with respect to Public Reporting of quality outcomes.
  • Provide input into CQSI data analytics development and reports.
  • Assume leadership role in the development of process improvement opportunities related to changes in clinical practice to support organizational goals. Apply innovative and creative skills to ensure that the process improvement opportunities are identified and addressed as well as meet the needs of quality and safety goals and meets regulatory guidelines.
  • Recommend changes to policies and procedures to senior leadership. Provide oversight of Policy and Procedure Committee and the revisions and improvements to the process.
  • Lead multidisciplinary teams, as assigned, in the development and ongoing progress of clinical outcomes to achieve organizational objectives of reducing resource utilization while promoting quality patient outcomes.
  • Conduct an analysis of clinical variance trends and recommendations for clinical practice changes. Investigate and implement creative methods to improve process.
  • *Performs in accordance with system-wide competencies/behaviors.
  • *Performs other duties as assigned.
  • Collaborate with professionals across UPMC to identify and support joint educational opportunities to change clinical practice. Active participation on System Quality, Safety, Regulatory and Infection Control teams.
  • ? Coach and advise professional staff in the formulation of their development plan.
  • ? Complete performance reviews to maintain compliance.
  • ? Demonstrate initiative to address complex, high-risk problems and translate them into opportunities and challenges with all levels of management.
  • ? Demonstrate responsiveness to the changing priorities and targets in the field of quality and patient safety, and patient experience.
  • ? Develop relationships and integrate all team members including physicians into the team's work. Report program findings, results, and changes at various settings and meetings. Form relationships with various setting in the continuum of care based on program issues/work.
  • ? Develop, implement, or utilize appropriate existing system data management capability that supports clinical program initiatives, decision support and regulatory compliance.
  • ? Ensure budgetary standards/expectations are met by monitoring and maintaining expenses and man-hour utilization.
  • ? Implement programs and activities, which support the organization's quality goals. Provide oversight for all appropriate UPMC pay for performance programs
  • ? Make decisions and evaluate outcomes with adequate knowledge, information and consideration of physician stakeholders and members of the all departments.



  • Master's Degree required.
  • 10 years Healthcare Related Experience required, with 5 years Management Experience required.
  • Certification in related area of expertise preferred.
  • Advanced interpersonal communications skills to assure a collaborative positive culture of quality and safety
  • Knowledge of various aspects of quality and process improvement through IHC, IHI, Lean Systems management and other techniques.
  • Experience in effective presentation of quality efforts to medical professionals of multiple disciplines
  • Excellent interpersonal skills and demonstrated Leadership qualities knowledge of Clinical Practices
  • Knowledge of regulatory requirements of multiple accrediting organizations including TJC, DOH and CMS Advanced analytic skills
  • Ability to effective and succinctly communicate verbally and in writing to all levels of the organizations.

Licensure, Certifications, and Clearances:
CPHQ (Certified Professional in Healthcare Quality) preferred.

  • Certified Professional in Healthcare Quality
  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

COVID-19 Vaccination Information

Individuals hired into this role must comply with UPMC’s COVID vaccination requirements upon beginning employment with UPMC. Refer to the COVID-19 Vaccination Information section at the top of this page to learn more.

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

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