Quality Manager

Position Summary

The Quality Manager is responsible for leading, coordinating, and implementing the Quality Improvement (QI) Program for the Clinic to ensure the delivery of safe, effective, and patient-centered care. This includes the collection, management and analysis of quality data, preparation of quality reports, and ensuring adherence to Accreditation Association for Ambulatory Health Care (AAAHC) standards, federal and tribal regulations, Government Performance Results Act (GPRA) reporting, and Healthcare Effectiveness Data and Information Set (HEDIS) measures. The Quality Manager works closely with leadership, providers, and staff to foster a culture of continuous improvement. The QI Manager will participate in quality-related audits and surveys in accordance with the quality plan.

Duties & Responsibilities

• Responsible for the development, monitoring, and presentation of internal quality measures and initiatives.
• Develop, implement, and maintain the clinic's Quality Improvement Program in alignment with AAAHC accreditation standards.
• Collaborates with the Compliance Manager to plan, coordinate, and facilitate Quality, Safety, and Utilization Review Committee Meetings.
• Lead and coordinate Electronic Health Record-based initiatives that enhance patient engagement, streamline communication, and improve overall satisfaction. This includes optimizing patient portals, integrating user-friendly sign-in processes, implementing feedback tools, and collaborating with clinical and IT teams to ensure digital solutions are intuitive, accessible, and aligned with quality care standards.
• Lead annual quality program evaluation and performance improvement projects.
• Coordinate organization-wide risk management, patient safety, and infection control activities, in collaboration with committee chairs and members.
• Ensure that quality requirements and changes are incorporated and measured to attain compliance with AAAHC standards, tribal policies, federal and state healthcare regulations.
• Prepare for and manage all phases of AAAHC surveys, including documentation, staff readiness, and coordinating tracking and reporting of clinical outcomes, and follow-up of corrective action plans as it pertains to quality.
• Oversee collection, validation, and submission of GPRA and HEDIS data in collaboration with clinical administrative staff.
• Monitor performance measures, identify trends, and recommend interventions to improve outcomes.
• Provide regular reports to leadership, providers, and committees on GPRA and HEDIS performance.
• Create and maintain dashboards and scorecards tracking quality, safety, and patient satisfaction indicators.
• Analyze data to identify gaps in care, disparities, and opportunities for improvement.
• Prepare monthly, quarterly, and annual quality reports for leadership, tribal council, and federal agencies.
• Oversee patient satisfaction survey processes and ensure follow-up on patient feedback.
• Collaborate with clinical and community health staff to design initiatives that improve patient care and population health outcomes. Participate in staff and management meetings as they relate to QI activities.
• Provide ongoing training to educate and train staff on quality improvement processes, accreditation requirements, and GPRA / HEDIS measures.
• Review QI tools and surveys and provide technical assistance to staff relating to Quality Efforts.
• Manage the incident reporting process in compliance with AAAHC standards, including tracking, investigation, root cause analysis, and follow-up to ensure resolution and prevention of recurrence.
• Develop and implement Quality Improvement (QI) studies based on identified trends, adverse events, or near misses, documenting methodologies, outcomes, and actions taken to enhance patient safety and quality of care.

Minimum Qualifications

Skills and Abilities

Physical Demands

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. While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to stand, walk, sit, use hands to finger, handle, or feel; and reach with hands and arms. The employee is occasionally required to stoop. The employee must occasionally lift and / or move up to 25 pounds. Position may require exertion up to 20 pounds of force occasionally and / or up to 10 pounds of force frequently or constantly lift, carry, push, pull or otherwise move objects. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

Work is performed in a health clinic setting. The noise level in the work environment is usually low to moderate. Will work with blood-borne pathogens and will require OSHA training. This job routinely uses standard office equipment such as computers, telephones, photocopiers, and fax machines. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Native Preference in hiring is given to qualified enrolled members of Paskenta Band of Nomlaki Indians and Native Americans in accordance with the Band's Preference Policy (Chapter 1-715 of the Paskenta Band of Nomlaki Indians Tribal Policies). Applicants claiming Indian Preference must submit verification of Indian heritage.

Seniority level

Employment type

Job function

Industries

Note : This description has been refined for formatting clarity while preserving the original content.

J-18808-Ljbffr