Position Summary
The Quality Improvement / Quality Assurance / Compliance Registered Nurse (QI/QA/Compliance RN) is responsible for leading and supporting the health center's quality improvement, patient safety, risk management, and regulatory compliance programs. This position ensures compliance with HRSA Health Center Program Requirements, Federal Tort Claims Act (FTCA) standards, Uniform Data System (UDS) reporting requirements, and applicable Federal, State of Alaska regulations.
The QI/QA/Compliance RN works collaboratively with clinical leadership, providers, nursing staff, and administrative teams to promote continuous performance improvement, patient safety, and high-quality, culturally responsive care in Alaska's rural, frontier, and remote healthcare environments.
Essential Duties and Responsibilities
Quality Improvement (QI)
- Lead and coordinate the organization-wide Quality Improvement (QI) Program
- Facilitate Plan-Do-Study-Act (PDSA) cycles and performance improvement initiatives
- Monitor, analyze, and trend Clinical Quality Measures (CQMs), including UDS clinical measures
- Identify gaps in care and work with clinical teams to implement and sustain improvement strategies
- Support value-based care, patient-centered medical home (PCMH), and care integration initiatives
- Incorporate health equity principles into quality improvement activities
Quality Assurance (QA)
- Conduct routine and targeted clinical chart audits to assess quality of care and documentation
- Monitor compliance with evidence-based guidelines, clinical protocols, and standing orders
- Participate in peer review and clinical case review activities
- Identify quality concerns and ensure corrective actions are implemented and monitored
- Track trends related to clinical outcomes and quality indicators
Compliance & Regulatory Oversight
- Ensure ongoing compliance with:
- HRSA Health Center Program Requirements, including the HRSA Operational Site Visit (OSV).
- Federal Tort Claims Act (FTCA)
- CMS and Medicaid requirements
- Alaska Board of Nursing and state regulations
- HIPAA, OSHA, and CLIA (as applicable)
- Maintain readiness for audits, surveys, and regulatory reviews, including the HRSA Operational Site Visit (OSV).
- Assist with policy development, review, and revision to ensure regulatory alignment
- Maintain compliance documentation and tracking tools
FTCA Risk Management & Reporting
- Coordinate the health center's FTCA Risk Management and Claims Prevention Program
- Support the annual FTCA Deeming Application
- Track, review, and trend:
- Incident reports
- Patient complaints and grievances
- Adverse events and near misses
- Conduct or support root cause analyses (RCAs) and corrective action plans
- Coordinate follow-up actions and monitor risk mitigation strategies
- Maintain required FTCA documentation and reporting records
- Collaborate with leadership and legal counsel as appropriate
Uniform Data System (UDS) Reporting
- Support and coordinate UDS reporting and data validation
- Validate clinical quality measure accuracy through chart audits and data review
- Collaborate with providers, nursing, IT, billing, and data teams to ensure data integrity
- Analyze UDS data to identify trends, gaps, and opportunities for improvement
- Use UDS results to inform quality improvement initiatives
- Support timely submission of UDS data in accordance with HRSA requirements
HRSA Operational Site Visit (OSV) Compliance & Reporting
- Ensure continuous compliance with HRSA Health Center Program Requirements
- Coordinate preparation for HRSA Operational Site Visits (OSVs), including:
- Evidence collection and organization
- Policy and procedure review
- Staff education and readiness
- Conduct or participate in mock site visits as needed
- Track OSV findings and coordinate Corrective Action Plans (CAPs)
- Support post-OSV reporting and ongoing HRSA communications
- Promote continuous compliance rather than event-based preparation
Infection Prevention & Patient Safety
- Coordinate and support the Infection Prevention and Control Program
- Monitor compliance with CDC, HRSA, OSHA, and Alaska public health guidance
- Conduct infection control audits and staff education
- Support outbreak response and exposure investigation
- Promote a culture of patient safety and quality improvement
Education, Training & Staff Support
- Provide education and training on:
- Quality improvement methods
- Documentation standards
- Compliance and risk management requirements
- Infection prevention and patient safety
- Support onboarding and annual competency requirements
- Serve as a quality and compliance resource for clinical and administrative staff
Data, Reporting & Committee Support
- Prepare quality, compliance, and risk management reports for:
- Leadership
- Quality Committee
- Board of Directors (as required)
- Participate in quality, compliance, and risk management committees
- Maintain accurate documentation and reporting records
Alaska-Specific Responsibilities
- Demonstrate understanding of rural, frontier, and remote healthcare delivery
- Support telehealth and remote care models used in Alaska
- Work effectively with diverse populations, including Alaska Native/American Indian communities
- Adapt quality and compliance programs to limited resources, weather-related access challenges, and workforce variability
- May require occasional travel to clinic sites, including travel by small aircraft or other rural transportation
Qualifications
Required
- Current, unrestricted Registered Nurse (RN) license in the State of Alaska
- Associate's or Bachelor's degree in Nursing (BSN preferred)
- Minimum 3-5 years of nursing experience, preferably in:
- Primary care or ambulatory care
- Community health or public health
- Rural or frontier healthcare
- Knowledge of healthcare quality improvement, regulatory compliance, and patient safety
- Strong analytical, organizational, and communication skills
- Proficiency with electronic health record (EHR) systems
Preferred
- QI/QA 2-3 years Direct Experience
- Experience in a FQHC, tribal health organization, or safety-net setting
- Experience with:
- HRSA UDS reporting
- HRSA OSVs
- FTCA risk management
- Bachelor's or Master's degree in Nursing, Public Health, or Healthcare Administration
- Quality or patient safety certification (e.g., CPHQ, CPPS)
Core Competencies
- Quality improvement methodology
- Regulatory compliance and audit readiness
- Risk management and patient safety
- Cultural humility and trauma-informed care
- Collaboration and communication
- Attention to detail and accountability
- Adaptability in rural and remote environments
Physical & Work Environment
- Combination of office-based and clinical area responsibilities
- Ability to sit, stand, and walk for extended periods
- Ability to lift up to 25 pounds
- May require travel between clinic or outreach sites
Reporting Relationship
- Reports to: Executive Director, CEO
- Works closely with: Medical Director, Nursing Leadership, Compliance Officer, Executive Team, and IT/Data teams
