- Develops, initiates, maintains, and revises policies and procedures for the general operation of the Continuous Quality Assurance and Performance Improvement (QAPI) Program, and Risk Management Program. Manages day-to-day operations of these programs.
- Reviews, assists in investigation, monitors, tracks, and trends incident reports to identify opportunities for system improvement and reports the information to leadership and/or the Board of Directors.
- Collaborates with other departments to promote process improvement and risk reduction strategies in response to complaint/concern data.
- Provides administrative oversight of the chronic disease management program, oversees patient education, facilitates appointment setting, and closes gaps in care.
- Collaborates in care coordination of services to patients with chronic medical conditions.
- Assists in the development of clinical outcome measures, related tracking and monitoring systems and a mechanism to integrate efforts into organization-wide quality initiatives, including value-based care.
- Chairs the Policy & Procedure (P&P) Committee, ensuring organizational leaders are aware of HRSA, ADHS, NCQA, and FTCA P&P requirements.
- Facilitates NCQA PCMH recognition and renewal efforts, including training and application tracking and submission.
- Actively participates in a variety of committees providing information, reports, and recommendations relevant to quality, and risk management.
- Completes an annual evaluation of the Continuous Quality Assurance and Performance Improvement Plan and recommends necessary updates and/or revisions.
- Chairs the QAPI Work Group with primary responsibility for preparing agenda, overseeing PDSA initiatives, and facilitating process and/or quality improvement efforts.
- Facilitates provider and system wide improvement efforts to meet organizational goals and performance requirements.
- Reviews and analyzes quality improvement and risk minimization indicators; prepares follow-up documentation and implement changes as needed.
- Helps ensure the safety and security of all the people, assets, and processes across the organization.
- Mitigates enterprise risks that may threaten the existence of the company, its reputation and stability.
- Analyzes agency compliance with regulations and other requirement from external organizations, such as the Arizona Department of Health Services (ADHS), OSHA, FTCA, and HRSA.
- Coordinates regulatory survey activities including, but not limited to, HRSA, ADHS, The Joint Commission, CMS, and NCQA.
- Participates in internal and external audit processes.
- Works in partnership with the clinical teams to enhance overall satisfaction for patients, visitors, and employees, including a proactive approach to resolving problems and complaints with respect to care, treatment, rights, and ability to access healthcare services.
- Develops and maintains SH care management/coordination program to improve overall patient care outcomes, within HRSA, ADHS, NCQA PCMH and CMS guidelines.
- Performs other job-related functions and activities as requested/required.
Supervisory Responsibilities:Direct Reporting: Nurse Care Manager, Quality Coordinator, Lead Chronic Disease Specialist
Indirectly Reporting: None
Scope of Supervisory Responsibilities: Day to day supervision
EDUCATION and/or EXPERIENCE:• Bachelor's Degree in nursing or healthcare administration or related field. Masters preferred.
• Minimum two (2) years management experience.
• Minimum five (5) experience in a healthcare organization.
• Additional education in risk/quality management and The Joint Commission standards preferred.
