Director of Quality and Risk Management

Community Health Partnership Of Illinois•Chicago, IL

23h

About The Position

Community Health Partnership of Illinois (CHP), a nonprofit healthcare organization providing primary medical, dental, and behavioral healthcare services to underserved communities, is seeking a Director of Quality and Risk Management. The Director leads the organization’s quality improvement, patient safety, regulatory compliance, and risk management programs. The role supports compliance with Health Resources and Services Administration (HRSA) Health Center Program requirements, The Joint Commission accreditation standards, and applicable federal and state healthcare regulations. Working closely with clinical leadership, Human Resources, and administrative teams, the Director promotes patient safety, reduces organizational risk, strengthens clinical performance, and fosters continuous quality improvement across CHP locations. The position supervises the Data Integrity Manager and oversees organizational data analysis activities.

Requirements

Certified Professional in Healthcare Quality (CPHQ) certification.
Certified Professional in Healthcare Risk Management (CPHRM) certification.
Current Basic Life Support (BLS) certification.
Current Advanced Cardiovascular Life Support (ACLS) certification.
Strong leadership, communication, organizational, and problem-solving skills.
Knowledge of The Joint Commission accreditation standards and Patient-Centered Medical Home (PCMH) certification requirements.
Understanding of healthcare regulations, clinical practices, medical terminology, and patient safety principles.
Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
Ability to lead quality and risk management initiatives while maintaining a safe, compliant, and professional healthcare environment.

Nice To Haves

Active Registered Nurse (RN) license.
In-depth knowledge of HRSA Health Center Program requirements, FTCA guidelines, and UDS reporting.
Advanced knowledge of The Joint Commission National Patient Safety Goals (NPSGs) and ambulatory care accreditation standards.
Experience with Electronic Health Records (EHR) and healthcare analytics platforms, such as Azara DRVS, i2i, or similar systems.
Infection Preventionist certification.
Experience working in ambulatory care, Federally Qualified Health Centers (FQHCs), or similar healthcare settings.
Experience managing quality improvement programs, regulatory compliance initiatives, and organizational risk management activities.

Responsibilities

Develop, implement, and oversee the organization’s Quality Improvement and Quality Assurance (QI/QA) programs.
Lead staff and Board Quality Improvement/Quality Assurance Committee meetings.
Establish and monitor data-driven quality initiatives, including Plan-Do-Study-Act (PDSA) cycles and Lean Six Sigma principles.
Track and improve Uniform Data System (UDS) clinical performance measures, including hypertension control, diabetes management, and colorectal cancer screening.
Supervise the Data Integrity Manager and oversee organizational data analysis activities.
Identify opportunities to improve patient outcomes, operational efficiency, and clinical performance.
Develop, implement, and oversee the organization’s Risk Management Program.
Manage incident reporting systems, monitor near-miss events, and coordinate proactive risk assessments, including Failure Mode and Effects Analysis (FMEA).
Oversee the annual Federal Tort Claims Act (FTCA) deeming application process.
Ensure required staff risk management training is completed, including infection control, HIPAA, and other applicable clinical safety topics.
Develop and maintain organizational emergency preparedness and Continuity of Operations (COOP) plans.
Promote a proactive culture of patient safety, accountability, and risk reduction.
Ensure compliance with the HRSA Health Center Program Compliance Manual and applicable regulatory requirements.
Serve as a primary subject matter expert for The Joint Commission accreditation in collaboration with the Director of Nursing and clinical leadership.
Coordinate accreditation readiness, including mock surveys, tracer activities, compliance assessments, and supporting documentation.
Oversee Patient-Centered Medical Home (PCMH) certification activities and ambulatory care accreditation requirements.
Prepare for and support HRSA Operational Site Visits (OSVs), FTCA deeming reviews, and other regulatory evaluations.
Monitor compliance with applicable federal and state healthcare regulations and licensing requirements.
Collaborate with Human Resources and clinical leadership on provider credentialing and peer review processes.
Guide clinical and administrative teams on quality improvement, risk management, and regulatory compliance.
Develop and maintain policies, procedures, reports, and documentation related to quality and risk management.
Promote collaboration, professional accountability, and continuous improvement across CHP locations.
Perform additional duties as assigned by organizational leadership.