ABOUT MARINHEALTH
Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch.
MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others.
Company:
Prima Medical Foundation dba MarinHealth Medical Network
Work Shift:
8 Hour (days) (United States of America)
Scheduled Weekly Hours:
40
Job Description Summary:
The Director of Quality provides strategic and operational leadership for network-wide clinical quality, performance improvement, patient safety and outcomes optimization efforts at MarinHealth Medical Network. This role is instrumental in fostering a culture of excellence and innovation across the clinically integrated network, which includes close collaboration with UCSF Health, Partnership HealthPlan, and several Independent Physician Associations (IPAs).
Reporting to the VPMA and Executive Director of Quality, the Director of Outpatient Quality is responsible for clinical quality strategy development, clinical data analytics, regulatory readiness, supporting a thriving patient safety/risk safety culture through cross-functional collaboration to ensure the consistent delivery of high-quality, patient-centered care. The Outpatient Quality Director supports risk event, grievance investigation and response, medical peer review working collaboratively with the enterprise Risk Manager and QMS teams through Just Culture and Evidenced-based Practice strategies.
Job Requirements, Prerequisites and Essential Functions:
Pay Range: $182,728 - $219,273
Essential Functions and Responsibilities:
Strategic Leadership
Design and execute strategies to elevate clinical quality, patient safety, and care outcomes across all network sites and affiliates.
Align quality initiatives with organizational goals, value-based care models, and population health strategies.
Responsible for annual Network clinical quality, patient safety/risk plans aligned with Medical Center plans and organization’s strategic goals.
Performance Improvement
Lead and sustain network-wide performance improvement projects using evidence-based methodologies.
Provide consultation for Network leaders and Performance Improvement teams on Improvement strategies and best practices.
Promote a proactive approach to identifying and resolving gaps in care processes and patient outcomes.
Manage assigned clinical quality staff and cross functional improvement teams .
Work collaboratively with Medical Center and UCSF data analytics and Population Health teams to drive successful performance improvement and metrics development.
Regulatory Compliance
Ensure continuous compliance with all relevant state and federal healthcare regulations, payer standards, and risk-based program requirements.
Maintain organizational readiness for audits and reporting, with a focus on quality integrity and transparency.
Collaborate with Medical Center Accreditation, Regulatory License Manager to ensure Outpatient sites under the Medical Center license sustain compliance with Medical Center policies and compliance standards.
Leads compliance complaint investigations and coordinates/ develops corrective action plans, responses and monitors through resolution.
Clinical Data & Analytics
Oversee clinical quality data collection, validation, and interpretation to guide operational and strategic decisions.
Drive adoption of actionable insights through user-friendly dashboards and reports for medical staff and leadership.
Liaison to Medical Center QMS data analytics team.
Collaboration & Partnerships
Foster deep partnerships with UCSF Health, enhancing integration of academic-level clinical excellence into community practice.
Serve as a strategic partner to Partnership HealthPlan and other IPAs, supporting value-based performance metrics and collaborative improvement initiatives.
Facilitate shared learning, peer benchmarking, and coordinated quality programs across the network.
Technology & Informatics
Consult with Informatics leads regarding the use of APEX (Epic-based EHR platform) to optimize clinical workflows, track key performance indicators, and support data-driven decision-making.
Lead the use of APEX (Epic-based EHR platform) to optimize clinical workflows, track key performance indicators, and support data-driven decision-making.
Collaborate with IT and clinical informatics teams to ensure accurate reporting, system optimization, and provider engagement.
MIPS Strategy & Optimization
Develop and manage organizational strategy for Merit-Based Incentive Payment System (MIPS) reporting.
Ensure accuracy, compliance, and continuous improvement in CMS quality program participation to maximize organizational performance and reimbursement.
Patient Complaints/Grievances
Serves as Outpatient Quality representative to enterprise Patient complaints/Grievances Committee.
Responsible for investigation and response to Outpatient Patient Grievances reported through insurers and external regulatory agencies.
Collaborates with Patient Experience and Relations staff to address patient grievances evolving to consideration of patient terminations.
Ensures patient terminations follow regulatory, accreditation standards.
Patient Safety/Risk Peer Review
Responsible for Network Patient Safety Event System (PSES) fostering safety event reporting, investigation and response using Just Culture philosophy and strategies.
Partner with Risk Manager on Serious Safety Event investigation, communication and response following BETA HEART strategies.
Manage assigned staff and support Network Quality and Medical Staff Peer Review committees and processes.
Represent Network on enterprise QMS teams developing quality and risk data systems.
Serves on Outpatient Threat Management Team.
Culture of Quality & Patient Safety
Champion a culture of continuous learning and accountability through, clinical quality and patient safety training programs, and leadership development.
Responsible for Network participation in BETA Health: HEART training programs, SCORE safety culture survey and BETA Health: HEART event response team.
Serve as a mentor and coach to teams across the network, promoting alignment and best practice adoption.
Infection Prevention & Control
Liaison to Medical Center Infection Control Program Manager for Network Infection Control
Manages outpatient Infection Control program and outpatient Infection Control staff including staff IC education, routine environment of Care rounds, disease outbreak response, hand hygiene program, infection prevention to ensure compliance with Infection Control standards and regulatory requirements.
Outpatient Clinical Research Activity
Qualifications:
Education
Master’s degree in Nursing (MSN), Pharmacy (PharmD), Healthcare Administration (MHA), Public Health (MPH), or a closely related healthcare field preferred.
Bachelor’s degree in Nursing or a related healthcare field required.
A non-healthcare Bachelor’s degree may be considered only if accompanied by a Master’s or Doctoral degree in a healthcare-related field.
Licenses/Certifications
Required:
Preferred:
Certified Professional in Healthcare Quality (CPHQ)
Certified Professional in Patient Safety (CPPS)
Certification in Infection Control (CIC)
Experience
Minimum of 5 years of progressive leadership in clinical quality, performance improvement, or patient safety within an acute care or ambulatory setting.
At least 3 years in a management or director-level position within a clinically integrated or value-based care environment.
Demonstrated success in leading cross-functional initiatives, leveraging data analytics, and engaging physician leadership in quality programs.
Experience with EPIC/APEX systems and MIPS reporting platforms.
Skills & Competencies
Strong analytical and critical thinking capabilities.
Exceptional written and verbal communication skills.
Advanced proficiency in quality measurement, reporting tools, and health informatics.
Proven ability to drive cultural transformation and lead multi-site quality programs.
Effective at managing complex projects with competing priorities and deadlines.
Accommodation:
Qualified applicants with disabilities may request reasonable accommodation during the application process by contacting Human Resources at 415-925-7040 or [email protected].
C.A.R.E.S. Standards:
MarinHealth seeks candidates ready to model our C.A.R.E.S. standards—Communication, Accountability, Respect, Excellence, Safety—which foster a healing, trust-based environment for patients and colleagues.
Health & Immunizations:
To protect employees, patients, and our community, MarinHealth requires measles, mumps, varicella, and annual influenza immunizations as a condition of employment (and annually thereafter). COVID-19 vaccination/booster remains strongly recommended. Medical or religious exemptions will be considered consistent with applicable law.
Compensation:
The posted pay range complies with applicable law and reflects what we reasonably expect to pay for this role. Individual pay is set by skills, experience, qualifications, and internal/market equity, consistent with MarinHealth’s compensation philosophy. Positions covered by collective bargaining agreements are governed by those agreements.
Equal Employment:
All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.
