Job Summary
The Director of Quality collaborates closely with executive leadership, medical leadership, operations, population health, and clinical teams to develop and implement data-driven strategies that improve patient outcomes, operational efficiency, and regulatory compliance. This role also supports organizational risk management activities, incident reporting processes, and corrective action planning. — all within a mission-driven organization committed to exceptional quality performance.
Essential Duties and Responsibilities
Quality Management
- Lead organizational-wide Quality Improvement (QI) and Performance (PI) programs in alignment with HRSA, FTCA, Joint Commission, NCQA, and other regulatory requirements.
- Develop, implement, and monitor annual quality improvement work plans, goals, dashboards, and performance metrics.
- Analyze clinical and operational data to identify trends, gaps, and opportunities for improvement.
- Monitor and report on UDS measures, HEDIS metrics, value-based care initiatives, patient satisfaction, and population health outcomes.
- Facilitate quality committees, peer review activities, root cause analyses, and performance improvement projects.
- Support clinical departments in implementing evidence-based practices and workflow improvements.
- Collaborate with leadership to establish corrective action plans and monitor progress towards organizational goals.
- Prepare reports, presentations, and data summaries for executive leadership, Quality Committee, and Board of Directors.
Value-Based Care & Risk Adjustment
- Maximize performance in value-based care contracts
- Drive CMS Star Rating strategy and manage health plan quality relationships.
- Oversee care gap closure initiatives, risk stratification programs, and population-level performance activities.
- Monitors and responds to CMS, NCQA, and regulatory changes across quality and risk adjustment programs.
Data Analytics & Reporting
- Oversee quality dashboards, scorecards, and organizational reporting.
- Utilize data to drive decision-making and performance improvement.
- Present quality performance data to executive leadership, board committees, providers, and operational teams.
- Collaborate with IT/EHR teams to improve reporting accuracy and clinical documentation.
- Ensure data integrity and timely submission of required reports.
Regulatory Compliance & Accreditation
- Support compliance with HRSA regulations, Risk management requirements. OSHA, HIPAA, and applicable federal/state regulations.
- Coordinate quality-related audits, surveys, and accreditation readiness activities.
- Assist with policy and procedure development, review, and implementation.
- Monitor compliance with clinical documentation standards and quality reporting requirements.
- Maintain readiness for site visits, operational reviews, and regulatory inspections
Risk Management Responsibilities
- Develop and lead the organizational risk management plan related to patient safety, incidents, grievances, and compliance concerns.
- Support incident reporting, investigations, documentation review, and follow-up activities.
- Track and trend adverse events, patient complaints, safety concerns, and operational risks.
- Collaboration with Human Resources, Compliance, Clinical Leadership, and Operations regarding risk mitigation strategies.
- Participate in developing and monitoring corrective action plans associated with risk events or audit findings.
- Support employee education related to patient safety, risk reduction, compliance, and quality standards.
- Maintain confidentiality and sensitivity regarding investigations and protected information
Leadership & Stakeholder Engagement
- Build, develop, and retain a high-performing team
- Collaborate with providers, nursing, operations, and IT, teams to improve workflows and care coordination.
- Promote a culture of continuous improvement, accountability, patient safety, and service excellence.
- Support strategic planning initiatives related to quality outcomes and operational effectiveness.
- Present performance results and strategic recommendations to senior leadership and medical staff committees.
Qualifications
- Bachelor’s degree required. Master’s degree preferred (MPH, MHA).
- 5 + years of progressive experience in clinical quality, population health, or value-based care operations;
- 2 + years of people leadership experience required.
- Experience in a Federally Qualified Health Center (FQHC), community health center, managed care, or ambulatory healthcare environment strongly preferred.
- Knowledge of HRSA compliance, FTCA requirements, UDS reporting, HEDIS measures, CMS Star Ratings and healthcare quality metrics preferred.
- Experience with incident investigations, risk management, and regulatory audits preferred.
- Strong analytics capabilities, including experience with EMR reporting, BI platforms, and population health data tools
- Proficiency in Microsoft Office Suite and healthcare reporting systems/EHR platforms required.
Physical Requirements
- Ability to sit, stand, walk, bend, and use standard office equipment for extended periods.
- Ability to travel between clinic locations as needed
Pay: $120,165.72 - $144,715.70 per year
Benefits:
- 401(k) matching
- Dental insurance
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Tuition reimbursement
- Vision insurance
Work Location: In person
