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QA Auditor

Houston Methodist

This is a Full-time position in Houston, TX posted May 14, 2022.

At Houston Methodist, the RN Transplant Quality Coordinator works collaboratively with medical/surgical staff, department leadership team members, and hospital leadership to ensure regulatory compliance with CMS Conditions of Participation for Transplant Centers, United Network of Organ Sharing (UNOS), Texas Department of Health Services (TDHS), and hospital accreditation agencies. Assists program leadership with the processes of continuous assessment and improvement of the quality of care delivered to the pre and post transplant and VAD patient through monitoring of clinical outcomes of Transplant/VAD Services including organizing, collecting, validating, compiling, analyzing, and reporting results of these services/programs. Oversees developing policies and procedures, and creating quality improvement processes associated with transplantation/VAD while facilitating adherence with regulatory agencies. Supports and promotes the organization-wide quality programThe [job title] is responsible for

Job responsibilities labeled EF capture those duties that are essential functions of the job.

PEOPLE – 20 %

  1. Communicates in an active, positive, and effective manner to all transplant team members, physicians and staff who are part of the interprofessional transplant program in order to facilitate quality activities and regulatory compliance goal attainment. (EF)
  2. Collaborates with management in monitoring and evaluating quality of care and patient outcomes for the transplant/VAD patient population based on standards of care as well as the findings of nursing research, hospital policies/procedures and applicable patient care protocols. (EF)
  3. Serves as a clinical resource to staff members. Fosters teamwork approach in all interactions with peers and team members and providing quality/compliance education in order to promote individual staff member accountability and responsibility. Demonstrates ability to work with all disciplines to achieve a common goal and promotes positive group dynamics as a leader and team member. Proactive and effective in developing and maintaining collaborative relationships with physicians, management and staff. (EF)

SERVICE – 15 %

  1. Promotes department/service line understanding of the Transplant CMPI program. Supports and assists management and physicians in coordinating and facilitating CMPI committee meetings and maintaining the CMPI documentation for the transplant center. (EF)
  2. Maintains ongoing clinical data in support of assessment and improvement of quality of care. Prepares internal or external clinical data requests. (EF)
  3. Facilitates collection of all clinical documents and data necessary in preparation for onsite review or regulatory response submission to any transplant regulatory agency. Participates as a liaison during certification/review site visits. (EF)


  1. Collaborates with Transplant Services leadership and staff to ensure ongoing compliance with the requirements, regulations and laws of local, state and federal regulatory agencies for transplant, including UNOS, TJC, and CMS. Updates departmental policies in collaboration with team to reflect current laws, regulations and requirements of the regulating bodies and works to ensure practice is consistent with regulatory requirements. (EF)
  2. Facilitates a interprofessional approach to identify opportunities for performance improvement, facilitates change, assist with follow-up and evaluation of performance improvement activities as evidenced by defined metrics and achievement of defined outcomes. Facilitates the development of action plans in collaboration with staff and management. Makes recommendations for change in practice to improve patient outcomes. (EF)
  3. In collaboration with administrative and physician leaders, develops and implements reporting processes regarding clinical quality across all organ transplant/VAD programs. (EF)
  4. Analyzes and confirms data reported by the Scientific Registry of Transplant Recipients (SRTR) including overseeing UNOS data entry audits in preparation for SRTR report publication. (EF)
  5. Participates in the development, implementation, evaluation and revision of order sets, policies, and other documentation. Monitors outcomes of current policy, process/system changes and reports variances to appropriate management and staff. (EF)
  6. Implements quality improvement projects involving data collection, validation, analysis, and reporting. Offers innovative solutions through participation in performance improvement projects. Contributes in department initiatives for quality and process improvement Identifies opportunities for improvement based on data analysis. Contributes to meeting departmental and organ program targets for quality and safety, on departmental dashboard. (EF)

FINANCE – 10 %

  1. Maintains and submits accurate data for hospital-based statistics and regulatory agencies such as UNOS/UNET, CMS, and Medicaid in order to ensure proper department financial management. (EF)
  2. Contributes to meeting departmental and organ program financial measures on departmental dashboard. (EF)


  1. Participates in transplant-specific continuous learning and growth. Applies evidence-based practice to daily work, such as reviewing the professional literature and attending professional meetings and sharing with colleagues. Stay abreast of and shares knowledge of current trends in transplant nursing and CMS and UNOS regulations. Identifies own learning needs and actively seeks educational opportunities, both formal and informal, to meet those needs. Completes and updates the individual development plan (IDP) on an on-going basis.

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.


  • Bachelor of Science degree or higher from an accredited School of Nursing


  • Five years of nursing experience. Transplant or Quality experience preferred
  • Experience with managing regulatory reporting and audit processes
  • Project management experience preferred


  • Texas RN license or temporary TX RN license, should obtain permanent license within 90 days. Compact license acceptable according to current Board of Nursing requirements.
  • American Nursing Credentialing Center (ANCC) recognized certification in Quality


  • Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations.
  • Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security.
  • Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles.
  • Demonstrates strong knowledge of organ failure clinical processes.
  • Demonstrates knowledge of hospital or specialty services regulatory reporting, accreditation, and audit processes.
  • Demonstrates knowledge and application of process improvement tools and techniques (statistical process control tools and team tools).
  • Ability to define problems, collect data, establish facts and draw valid conclusions and evidence performance improvement via measurable results.
  • Ability to enter and abstract data, as well as the ability to utilize data to facilitate the improvement and change in processes. Able to navigate transplant applications and data systems (UNET, DonorNet, Tiedi).


Work Attire Yes/No
Uniform No
Scrubs No
Business professional Yes
Other (dept approved) No


On-Call* No (for Non-Exempt or Exempt jobs)
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Event, etc) regardless of selection above.  
May require travel within No  
Houston Metropolitan area  


May require travel outside No
of Houston Metropolitan area  

**Travel specifications may vary by department.

Please note any other special considerations to this job: __________________________

Company Profile:

Since its founding in 1919, Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation’s leading centers for medical education and research. In 2020, U.S. News & World Report named Houston Methodist Hospital to its top ranked Honor Roll for the fourth time and second consecutive year. 2020 also marked the ninth year in a row Houston Methodist Hospital has been named the No. 1 hospital in Texas. Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 952 operating beds, 85 operating rooms and over 8,000 employees, Houston Methodist offers complete care for patients from around the world.

The same high-quality care for which Houston Methodist is known is available at several Emergency Care Centers in Houston and the surrounding areas. These Emergency Care Centers house exam rooms, full digital radiography suite, low radiation dose 16-slice CT scan, ultrasound and a full on-site stat chemistry lab.