JOB SUMMARY: The Manager, Quality & Risk leads day-to-day quality improvement, patient/resident safety, risk-management, and regulatory-readiness activities across the organization. This position translates organizational priorities into measurable improvement work, oversees quality and risk staff, and partners with clinical and operational leaders to reduce harm, strengthen compliance, and sustain survey readiness. The role supports a CAH-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program, as required under the CAH Conditions of Participation, and coordinates quality activities across hospital, SNF, and clinic settings.
PERFORMANCE DIMENSIONS AND TASKS
Essential Job Functions
The duties listed below are the essential functions of this position. Employees must be able to perform these essential functions, with or without reasonable accommodation. This list is intended to describe the primary responsibilities of the position and is not intended to be an exhaustive list of all duties. Additional job-related duties may be assigned as needed.
Quality and Performance Improvement
• Coordinate implementation, maintenance, and evaluation of the organization-wide QAPI program for acute care, emergency services, swing-bed services, the distinct-part SNF, and RHCs.
• Facilitate development of annual quality plans, departmental dashboards, performance-improvement projects, corrective-action plans, and sustainability monitoring.
• Collect, validate, trend, analyze, and present quality, safety, utilization, infection-prevention, patient-experience, and regulatory data.
• Partner with leaders to select meaningful measures based on high-risk, high-volume, problem-prone, and mission-critical services.
• Apply structured improvement methods, such as Plan-Do-Check-Act, root-cause analysis, failure-mode analysis, and process mapping.
• Prepare concise reports, scorecards, and recommendations for Quality Committee, Medical Staff, Infection Prevention, Safety Committee, SNF Quality Assurance/Performance Improvement Committee, Compliance Committee, and Governing Board review.
• Track action items, responsible owners, target dates, outcomes, and effectiveness of corrective actions.
Risk Management and Patient Safety
• Oversee the intake, review, investigation, trending, and follow-up of patient, resident, visitor, employee, and facility events, including near misses, complaints, grievances, adverse events, and potentially reportable incidents.
• Facilitate or support root-cause analyses and serious-event reviews; ensure timely documentation, corrective actions, leadership escalation, and follow-up monitoring.
• Identify system vulnerabilities and collaborate with clinical, operational, medical-staff, and human-resources leaders to mitigate risk.
• Maintain incident-reporting standards and educate staff on just culture, event reporting, disclosure processes, and safety escalation pathways.
• Support claims, subpoenas, record requests, liability matters, and insurer/risk-pool communications in coordination with the Director and organizational leadership.
• Assist with maintenance of risk registers, loss-prevention initiatives, safety rounds, environmental rounds, and emergency-management after-action improvement plans.
Regulatory and Survey Readiness
• Maintain ongoing readiness for CMS, California Department of Public Health, California Title 22, accrediting-bodies (TJC, TCT), and other applicable regulatory surveys.
• Conduct and coordinate tracers, mock surveys, document reviews, focused audits, and rounds across the hospital, SNF, and RHC locations.
• Collaborate with department leaders to develop plans of correction and evidence of compliance; monitor completion and validate sustained implementation.
• Support survey preparation, on-site survey coordination, document production, staff coaching, and post-survey corrective-action follow-up.
• Monitor regulatory and accreditation updates and recommend policy, process, education, or documentation changes to the Director.
SNF and Rural Clinic Oversight
• Coordinate quality, resident-safety, grievance, and performance-improvement activities for the distinct-part SNF in collaboration with the SNF Administrator, Director of Nursing, Medical Director, and interdisciplinary team.
• Support SNF quality-assurance activities, including required committee documentation, minutes, follow-up actions, and governing-body reporting.
• Coordinate clinic quality monitoring and support RHC program evaluations, including assessment of the clinics’ total operations, utilization of services, and adherence to clinic policies. Federal RHC rules require a biennial program evaluation.
• Ensure quality data and improvement work reflect the unique workflows, staffing, access barriers, and care transitions common to rural care settings.
Leadership and Staff Supervision
• Directly supervise Quality/Risk team members, including hiring input, onboarding, work assignment, coaching, competency assessment, performance evaluation, and professional development.
• Establish priorities and workflows that ensure timely completion of investigations, audits, reporting, committee support, and improvement activities.
• Develop education and tools for leaders and frontline staff on quality, risk prevention, regulatory readiness, event reporting, and performance improvement.
• Serve as a visible resource and collaborative partner to nursing, medical staff, ancillary departments, revenue cycle, health information management, clinics, SNF staff, and executive leadership.
• Perform other duties within the scope of the position as assigned.
Position-Specific Performance Expectations
• Timely, complete investigation and closure of safety events, grievances, and corrective-action plans.
• Accurate, actionable quality and risk dashboards delivered on the established reporting schedule.
• Documented improvement in selected safety, quality, and regulatory-readiness measures.
• Effective staff supervision and reliable committee, audit, tracer, and survey-readiness support.
• Sustained compliance with CAH, SNF, RHC, federal, state, and accreditation requirements applicable to the organization. CAHs must maintain an ongoing, organization-wide, data-driven QAPI program, while the CAH model also requires quality-assurance arrangements with an appropriate external entity.
QUALIFICATIONS
Education:
• Bachelor’s degree in nursing, healthcare administration, public health, quality, risk management, or a related field – Required (equivalent relevant clinical and quality/risk experience may be considered).
• Master’s degree in nursing, healthcare administration, public health, business administration, or a related field - Preferred
Licensing:
• Current California RN license - Preferred
• Certification in healthcare quality, patient safety, healthcare risk management, infection prevention, or healthcare compliance, such as CPHQ, CPPS, CPHRM, HACP, CHC, or CIC - Preferred
• Other relevant California clinical licensure may be considered based on organizational needs.
Work Experience:
• Minimum of five years of progressively responsible healthcare experience, including at least three years in quality improvement, patient safety, risk management, compliance, accreditation, or clinical leadership – Required
• Minimum of three years of supervisory, lead, project-management, or team-coordination experience - Required
• Experience in an acute-care hospital - Required
• Experience with CAH QAPI, SNF QAPI, grievance management, and quality reporting - Preferred
• experience in a Critical Access Hospital, rural hospital, SNF, RHC/FQHC, or multi-site healthcare environment - Preferred
Knowledge, Skills and Abilities Requirements:
• Working knowledge of CMS Conditions of Participation, California Title 22, CDPH survey processes, and accreditation standards applicable to the organization.
• Demonstrated experience with event investigation, root-cause analysis, quality-data analysis, corrective actions, committee facilitation, and regulatory survey readiness.
• Proficiency with Microsoft Excel, Word, PowerPoint, and quality-data/dashboard reporting tools.
• Familiarity with rural-health access challenges, care coordination, and resource-constrained improvement strategies –
• Clinical and operational judgment with a systems-based approach to safety and quality.
• Ability to interpret regulations and convert requirements into practical workflows, audits, and education.
• Strong analytical skills, including data validation, trending, dashboard development, and interpretation of variation.
• Clear, tactful communication in sensitive investigations and high-stakes regulatory matters.
• Ability to lead interdisciplinary teams without direct authority.
• Strong organizational skills, discretion, follow-through, and ability to manage competing deadlines.
• Commitment to a just culture, confidentiality, patient/resident rights, and continuous improvement.
Language Requirements:
• Proficient in spoken and written English.
Physical Requirements:
• Primarily sedentary work with frequent sitting and use of a computer.
• Periodic standing and walking throughout hospital, clinic, and skilled nursing facility environments.
• Must be able to communicate effectively in person, by telephone, and electronically.
• Perform repetitive hand and finger movements associated with computer and office equipment use
• Occasionally lift, carry, push, or pull up to 20 pounds.
• Requires the ability to travel between MMHS locations and navigate patient-care and administrative areas.
• Must be able to perform the essential functions of the position with or without reasonable accommodation.
Working Conditions:
• Primarily office-based with regular rounding and work in patient-care, resident-care, and clinic environments.
• May require periodic travel among organization sites and occasional schedule flexibility for urgent event reviews, surveys, committee meetings, or regulatory response activities.
• Must protect confidential information and handle quality, risk, peer-review, and privileged materials in accordance with applicable law and organizational policy.
DISCLAIMER:
The preceding job description has been designed to indicate the general nature and level of work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.
