Description

Position Summary

The Quality Manager is responsible for leading, coordinating, and implementing the Quality Improvement (QI) Program for the Clinic to ensure the delivery of safe, effective, and patient-centered care. Responsibilities include managing and analyzing quality data, preparing reports, and ensuring adherence to AAAHC standards, federal and tribal regulations, GPRA reporting, and HEDIS measures. The Quality Manager fosters a culture of continuous improvement and participates in audits and surveys per the quality plan.

Essential Duties/Responsibilities
• Develop, monitor, and present internal quality measures and initiatives.
• Develop, implement, and maintain the Quality Improvement Program per AAAHC accreditation standards.
• Collaborate with the Compliance Manager to plan, coordinate, and facilitate Quality, Safety, and Utilization Review Committee meetings.
• Lead Electronic Health Record (EHR)-based initiatives to enhance patient engagement and satisfaction.
• Lead annual quality program evaluations and performance improvement projects.
• Coordinate risk management, patient safety, and infection control activities.
• Ensure integration and measurement of Quality requirements for compliance.
• Prepare for and manage all phases of AAAHC surveys, documentation, and corrective action follow-up.
• Oversee collection, validation, and submission of GPRA and HEDIS data.
• Monitor performance, identify trends, and recommend interventions for improvement.
• Provide regular reports on GPRA and HEDIS to leadership and committees.
• Create and maintain dashboards and scorecards for key quality indicators.
• Analyze data to identify gaps in care and opportunities for improvement.
• Prepare monthly, quarterly, and annual quality reports for leadership, tribal council, and agencies.
• Oversee patient satisfaction surveys and follow-up actions.
• Collaborate with staff to design care and population health improvement initiatives.
• Provide ongoing staff training on quality processes, accreditation, GPRA/HEDIS.
• Review QI tools and provide technical assistance for Quality projects.
• Manage incident reporting per AAAHC: tracking, investigation, and root cause analysis.
• Develop and implement QI studies based on trends, events, or near misses.
• Perform other duties as assigned.

Qualifications

Required Education & Experience
• Bachelor's Degree in Healthcare Administration, Nursing, Public Health, or related field.
• Experience with Indian Health Service (IHS) and/or tribal health programs.
• Experience managing large-scale quality improvement projects.

Preferred Education & Experience
• Master's Degree in Healthcare Administration, Public Health, Nursing, or a related field
• Certification in quality or process improvement methodologies such as Six Sigma, Lean, or Certified Professional in Healthcare Quality (CPHQ).

Licenses/Certificates
• Valid CPR Certification
• Valid California Driver's License

Pre-Employment Requirements
• Pre-employment drug testing.
• Department of Justice fingerprint clearance through Federal, State, and Child Abuse Index.

Working Environment & Physical Demands

Working Environment: Work is performed in a health clinic setting. The noise level in the work environment is usually low to moderate. Will work with blood-borne pathogens and will require OSHA training. This job routinely uses standard office equipment such as computers, telephones, photocopiers, and fax machines. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to stand, walk, sit, use hands to finger, handle, or feel; and reach with hands and arms. The employee is occasionally required to stoop. The employee must occasionally lift and/or move up to 25 pounds. Position may require exertion up to 20 pounds of force occasionally and/or up to 10 pounds of force frequently or constantly lift, carry, push, pull or otherwise move objects. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Other Requirements of Employment

Background Check Requirements:

Pre-employment Drug Testing and a Department of Justice Fingerprinting clearance through Federal, State and Child Abuse Index is a contingency for an offer of employment. Criminal clearances are obtained to protect the welfare and safety of clients receiving services at Rolling Hills Clinic.

Vaccination Requirements:

Provide vaccination records to show proof of immunity for TB, Measles, Mumps, Rubella, Varicella, TDAP & Hep B. If the records are more than 10 years old, titers are required to confirm immunity.