About us:
Neighborhood HealthSource provides quality primary care, community health, & behavioral health services in North & Northeast Minneapolis & Coon Rapids. We work with individuals & families across the lifespan with the mission of increasing access to quality care for all who need it. It is the mission of Neighborhood HealthSource to improve the health of our communities by providing quality healthcare services that are affordable and accessible while advancing health equity for all. What does our mission look like in action? We envision a community in which cost is never a barrier to access, where every person can access comprehensive health care from compassionate, qualified, well-trained, and respectful staff, where everyone honors diversity and culture, and where health equity is achieved.
Position Summary:
Develops, implements and manages clinical quality, risk management, program evaluation, and various reporting requirements for the organization in accordance with NHS’ mission and strategic goals, federal and state laws and regulations, quality performance and outcome objectives, and accreditation standards
Essential Functions:
1. Management of Internal Quality Improvement Functions
- Integrates the principles and values of continuous quality improvement (CQI) throughout NHS and ensures the implementation of quality improvement-quality assurance (QI-QA) operating procedures. Develops a conceptual framework for quality measurement and improvement activities across clinic sites.
- Works with the Medical Director to develop or update existing QI-QA measures, protocols, policies and operating procedures, and clinical workflows in consultation with relevant staff.
- Educates staff on quality and systems improvement concepts and tools.
- Ensures implementation of workflows in the electronic medical record (EMR) and Practice Management System that facilitate staff’s ability to provide complete documentation and coding to produce accurate quality reporting. Provides training and technical support, as necessary.
- Monitors QI-QA outcomes and ensures completion of quality improvement assessments. Completes the gathering and analysis of CQI data, including audits of staff compliance with workflows; converts data into statistics for analysis. Provides feedback in-person and via reports to departments on trends and needed Action Plans.
- Works with Medical Director, provider staff and other clinical quality Champions to pilot changes in workflows and to implement action plans designed to support improvement efforts. Serves as project manager for implementing pilots, improvement projects, operating procedures, and action plans.
- Manages NHS Clinical Operations and Quality Improvement Team including preparing agenda and minutes for weekly meetings, acting as a facilitator for meetings. Manages meeting schedule as well as tracks activities and priorities.
2. Completion of Data Submissions and Routine Monitoring of Clinical Outcomes Performance
- Prepares data submissions for the following parties by reviewing specific clinical indicators and information located in the patient registration and medical records:
- HRSA Universal Data Set (UDS) and other PHS 330 grant measures
- Other reporting of clinical improvement outcomes as directed for miscellaneous grant reports and collaborations, such as the Minnesota Association of Community Health Centers
- Develops content to be included in the quarterly QI report and presents to Management Team, All-Staff/Department meetings as needed, and Board and Board CQI Committee as requested
- Primary responsibility to coordinate completion of Health Plan HEDIS and other responses to quality related inquiries. Works with Director of Clinical Operations, Medical Records personnel and ROI Vendor to complete such requests.
- Prepares formal clinical quality dashboards populated by UDS results, including year- over-year improvement, peer group comparison and assessment of performance against goals. Presents data to staff, Continuous Quality Improvement (CQI) Committee and Board in conjunction with Medical Director.
- Monitors priority measures monthly and reports findings to Clinical Operations and Quality Improvement Team. Tracks outcomes as required by grants, contracts, or agency need, as assigned. Works in partnership with Director of Community Engagement and Grants Management to compile and present grant-reporting requirements as needed.
- Completes required monthly UDS submissions to FUHN and MNACHC
3. Regulatory and Clinical Risk Management Support
- Provides regulatory guidance and interpretation of clinical-based HRSA requirements; assists with maintaining or correcting processes to ensure compliance with HRSA requirements
- Coordinates the completion of the annual HRSA FTCA Malpractice coverage submission
- Works with Senior Leadership to ensure the implementation of Risk Management policies to minimize clinical risk within the organization
- Conducts quarterly medical malpractice risk assessments and related quarterly audits, including developing and maintaining dashboards and organizational performance tracking, to ensure Risk Management policies and practices adherence
- Compiles and reports annual trends from risk assessments to Executive Director in compliance with HRSA guidance
- Project manages implementation of follow-up decisions made as a result of quarterly and annual risk assessment trends, including but not limited to, staff trainings and workflow adjustments
- Supports HRSA practitioner credentialing and privileging requirements as follows:
- Coordinates with HR and Patient Accounting to ensure Provider credentialing applications and files are complete for review by Medical Director or other approving Manager
- Coordinates annual peer chart review process and completes record keeping process
- Prepares individual provider quality dashboards at least annually
- Assists NHS Management team to prepare for HRSA Federal Operational Site Visit (OSV) and, as needed, HRSA FTCA site visits
- Follows HRSA site visit manual to compile all materials for review
- Ensures compliance with areas of review relevant to Quality Improvement, Risk Management, Clinical Staffing, FTCA, Required Services, Performance Analysis, and other areas as needed
4. Collaborative Functions
- Collaborates with Electronic Medical Record (EMR) consultant/project manager and EMR Vendor User Group (MINN) to ensure data systems and programs adequately support CQI activities, including working with EMR specialist on maintaining analytics software quality measure reports and patient registry and list capabilities
- With Medical Director, plans and facilitates quarterly Board CQI committee meetings including overseeing meeting scheduling, agenda and material dissemination, and meeting minutes preparation
- Collaborates with local federally-qualified health centers (FQHCs), as needed, on issues that further quality improvement efforts and/or that are mandated by grants, contracts or organizational partnerships, e.g., MNACHC and FQHC Urban Health Network (FUHN) Group Quality Improvement Committee
- Participates in development of Strategic Plan, Tactics, and work plans as requested by Executive Director
5. Other Duties
- Supervises Quality Improvement Assistant
- Responsibilities include interviewing, hiring, and training; planning, assigning, and directing work; setting benchmarks; evaluating, rewarding and disciplining employee(s); mentoring, coaching and developing staff; addressing complaints; approving payroll time records, PTO and other staff absences to assure adequate site coverage
- Prepares diagnosis-based reports and/or audits and registries required to support strategic initiatives, as requested
- Secures and supervises interns and volunteers for quality improvement projects, audits and data submissions. Volunteers and interns include, but are not limited to, Public Health students, DNP students, Pre-Medical, and Medical students
Core Requirements:
- Participates in Strategic Plan Tactic Implementation as directed (Managers)
- Participates in strategic and operational planning to ensure quality care, optimal patient flow, provider productivity, and continuity of care (Managers)
- Represents NHS at outside meetings, as requested (Managers)
- Works collaboratively and respectfully with staff and others—individually and as part of a team—to achieve optimal efficiency, outcomes and morale
- Interacts in a culturally competent manner with individuals and groups from diverse backgrounds, including but not limited to: socio-economics, race and ethnicity, nationality and religion, both in-clinic and in the community
- Maintains excellent and punctual attendance
- Attends and actively participates in staff and departmental meetings
- Attends agency functions and meetings as relevant or required
- Works at any or all NHS clinics, as needed
- Uses computer daily including e-mail, word documents, spreadsheets, patient management system, electronic health record, and patient portal, as needed to carry out essential job functions
- Maintains any required licensure/certification
- Demonstrates commitment to agency mission and goals
- Abides by corporate compliance program, HIPAA regulations and other agency policies and procedures
- Utilizes Patient Portal to access patient information and communicate with patients, as relevant
- Plans, organizes, and multitasks
- Speaks, understands, reads and writes English sufficiently to carry out all essential duties
- Performs other duties as assigned
Qualifications:
Required
- Minimum Bachelor’s degree in public health or clinical healthcare area including quality improvement education or equivalent. At least three years’ quality-related work experience or equivalent combination of education and experience.
- Knowledge of quality improvement, utilization and risk management areas
- Experience with Plan Do Study Act (PDSA) Cycles and Root Cause Analysis
- Able to build and motivate teams with demonstrated leadership and facilitation experience
- Excellent written and verbal communication and problem-solving skills
- Demonstrated effectiveness in the realization of performance objectives and previous experience in performance-based evaluations
- Ability to work as a liaison with patients, government agencies, grantors, managed care and other health care organizations to coordinate quality measurement and performance activities
- Experience conducting effective training and presentations
- Able to prioritize, organize and carry out work assignments independently and efficiently
- Proficient in use of computer programs including Word, Excel and PowerPoint
Preferred:
- Prior work in a healthcare setting, including primary care and/or managed care experience. FQHC experience is a plus.
- Familiarity with documentation and reporting in an EMR
- UDS reporting experience
- MPH or MHA
Benefits: Neighborhood HealthSource offers competitive pay and benefits among community health centers. Eligible employees (24 hours/week or more) receive benefits including:
- Generous paid time off and holidays
- Health insurance
- Life insurance
- Disability insurance
- Flexible spending account
- Optional 403(b) retirement, vision, and dental plans
- $60 phone stipend
- Federal Loan Repayment Eligibility for Medical/Behavioral Health Providers and RNs
NHS is an AA/EOE Employer
Job Type: Full-time
Pay: $58,240.00 - $72,800.00 per year
Education:
Work Location: In person
