Manager: Quality and Risk Management

Pagosa Springs Medical Center • Pagosa Springs, CO

1d • $82,680 - $127,816 • Onsite

About The Position

This key management position is responsible for leading an effective and sustainable, data-driven, facility wide, and quality assurance and performance improvement (QAPI) program. The QAPI and Risk Manager maintains a quality infrastructure that includes development and implementation of decision tools, clinical processes and guidelines, care management programs, and outcome measurement assessments. This manager leads both the Quality Counsel and the Performance Improvement Committee. The QAPI and Risk Manager assures that PSMC participates fully with regulatory quality programs both federal and state. The Manager participates in external committees and meetings to develop critical relationships with community and professional resources. The QAPI and Risk Manager has strong leadership, interpersonal and communication skills, with the ability to analyze situations and arrive at creative solutions to complex healthcare challenges. The Manager of QAPI and Risk is responsible for the overall management of assigned departments for Pagosa Springs Medical Center. These services include, but, are not limited to: Quality Assurance Performance Improvement Risk Management Such management includes: Oversight of effective day-to-day operations; Development, implementation of processes to improve clinical care for the appropriate patient population; Managing staff and resources within the department; Implementation of new services and programs as directed by Leadership; Effective fiscal management; Coordination and collaboration with the medical staff, other managers / leaders and staff; Participation in hospital-wide problem solving, sharing of information and other joint efforts; Recommending and implementing innovative organizational processes which support the safe and effective provision of patient care and improve patient outcomes. Join a Hospital That Feels Like Family – In a Town That Feels Like Home Pagosa Springs Medical Center is an award-winning, independent Critical Access Hospital serving the residents and visitors of Archuleta County and the surrounding region. As a modern rural hospital, PSMC delivers exceptional emergency, primary, and specialty care supported by advanced technology, a collaborative medical staff, and a leadership team committed to quality, safety, and patient-centered service. At PSMC, you are not just a number – you are a valued team member whose contributions make a real difference. We prioritize professional growth, meaningful work, and a positive, supportive workplace culture grounded in our WISER values: Wholeness, Integrity, Stewardship, Excellence, and Respect. What you’ll find at PSMC: A supportive, collaborative culture where people truly care about each other Modern facilities and growing service lines Leadership that listens and invests in staff Opportunities to learn, grow, and advance your career A place where you can have direct impact on patient care and community wellness Live Where Other People Vacation Pagosa Springs is a mountain paradise tucked among the rugged peaks of the San Juan National Forest. Here, you can step into nature the moment you clock out: Relax in our world-famous hot springs Ski or snowboard at Wolf Creek Ski Area – “the most snow in Colorado,” just 30 minutes away Explore hundreds of miles of hiking, biking, and off-roading trails Enjoy fly fishing, rafting, or paddle boarding on pristine rivers and lakes Experience warm, friendly community with local festivals, live music, farmers markets, and small-town charm If you’re looking for meaningful work, work-life balance, and a community that embraces you – PSMC and Pagosa Springs are the perfect place to build your future.

Requirements

• Bachelor’s degree in a healthcare related field is required.
• Minimum of five (5) years clinical experience is required.
• Minimum of two (2) years supervisory or management experience is required.
• Minimum of two (2) years experience in Quality Assurance, Performance Improvement and/or Risk Management is required.
• Current Colorado licensure as RN, if applicable.
• Current AHA BLS certification for Heart Saver is required.
• Computer skills sufficient to handle email, documents, spreadsheets and project management software.
• Demonstrates ability to read, write, and clearly express one’s self in English 100% of the time.
• Demonstrates ability to listen.
• Demonstrates ability to express or exchange ideas by means of spoken work, to impart oral information to others or the public and to convey detailed spoken instructions to others accurately, loudly, or quickly.

Nice To Haves

• Healthcare Management and/or Clinical degree is strongly desired but not required.
• CPHQ (Certified Profession in Healthcare Quality) is strongly desired but not required. If not certified, successful completion of certification within one year of hire date is required.
• CPHRM (Certified Professional in Healthcare Risk Management) is strongly desired but not required. If not certified, successful completion of certification within one year of hire date is required.
• Additional languages desired but not required.

Responsibilities

• Oversight of effective day-to-day operations
• Development, implementation of processes to improve clinical care for the appropriate patient population
• Managing staff and resources within the department
• Implementation of new services and programs as directed by Leadership
• Effective fiscal management
• Coordination and collaboration with the medical staff, other managers / leaders and staff
• Participation in hospital-wide problem solving, sharing of information and other joint efforts
• Recommending and implementing innovative organizational processes which support the safe and effective provision of patient care and improve patient outcomes
• Provides managerial and operational oversight of the Quality Assurance and Performance Improvement (QAPI) program
• Quality Assurance and Performance Improvement (QAPI) activities include quality assessment and monitoring, quality reporting, and organizational performance improvement
• Creates and maintains the QAPI Program and Annual Plan
• Assist with identifying key performance indicators for on-going monitoring
• Identifies and facilitates process improvement activities within the organization
• Supports other managers in developing department specific QAPI activities
• Collects, analyzes and reports quality related data as required
• Maintain compliance with external regulatory quality programs including but not limited to HQIP, MBQIP, MIPS, PI, HTP and CMS IQR and OQR
• Manages HCAPHS program
• Participates in the Periodic Program Evaluation for the hospital and clinic
• Act as Chairperson for the Quality Council and Performance Improvement Committee
• Provides staff orientation to the QAPI and patient safety program
• Reports and analyzes data and information pertinent for organizational and project decision making
• Participates in Utilization Management Committee and activities to support ongoing quality assurance and performance improvement
• Clinical patient safety is inclusive of Risk Management activities
• Interact with patients in resolving quality related complaints
• Facilitates Root Cause Analysis activities related to quality/patient safety issues
• Effectively coordinates hospital wide system for risk identification, investigation, and mitigation. Follows issues to resolution, maintains, and reports statistics
• Completes federal and state required reporting (CDPHE and FDA)
• Completes biannual patient safety survey
• In coordination with the Chief Administrative Officer, facilitates communications with insurer regarding actual or possible claims against PSMC
• Maintains appropriate accesses to data management and reporting sites
• Assures all projects are properly planned, vetted and presented to applicable committees
• Assures that projects are documented and tracked with detailed reports
• Oversees projects to support completion on schedule, to plans and on budget
• Provides data and presents monthly statistical reports to present to position’s supervisor (which in turn may be presented to the CEO and/or Board of Directors)
• Successfully meet Department Key Performance Indicators that are consistent with the PSMC Strategic Plan, Quality objectives and other PSMC goals and approved by the CNO (KPIs are subject to change from time to time)
• Additional duties as assigned and/or resulting from organization plans, committee projects, annual goals, and assignments
• Coordinates, schedules and documents minutes of monthly staff meetings
• Assures staff attends a minimum of 6 staff meetings / year and stays up to date by reading and signing posted minutes for review
• Demonstrates knowledge of rules and regulations under Chapter 1, 2, Appendix – W as mandated by the Colorado Department of Public Health and the Environment (CDPHE)
• Maintains a state of readiness for unannounced survey
• Demonstrates in-depth knowledge of regulatory and performance improvement requirements as required by PSMC, Hospital Transformation Project, HCPF, HQiP, and other potential agencies
• Participates in regularly scheduled department quality meetings
• Implements performance improvement projects through education and training as appropriate
• Responsible for monthly reporting of department statistics
• Verifies and reports the statistics to the Administrative Assistant and Controller by the 5th of each month
• Has detailed knowledge of the EHR and works collaboratively with the Informatics Department to improve and disseminate workflow changes to staff
• Develops and/or maintains knowledge of Microsoft Access, Excel and others to collect, analyze and report meaningful data
• Responsible for facilitating the completion of required annual competencies for the department
• Utilizes processes and principles of continuous performance improvement in collaboration with members of the healthcare team to improve the patient experience and/or care
• Responsible for ensuring quality risk management events, patient complaints, employee exposure or injuries are reported and appropriate follow-up is completed
• Directs and initiates the onboarding and training / education for all assigned staff
• Works in coordination with the Safety Committee to facilitate training of staff in emergency management exercises / drills
• Ensures department policies / procedures are up to date and compliant with state and federal regulations
• Actively participates and directs department needs for the recruitment, training and retention of staff
• Reviews and reconciles staffing timesheets in PayCom and finalizes payroll bi-monthly
• Takes responsibility for department budget, adjusting staffing and utilizing supplies appropriately and avoids waste when possible
• Has extensive knowledge of staffing roles under the QAPI umbrella. This includes the capability to assume these roles and perform 100% of these job duties as needed
• Complete annual evaluations for all assigned staff
• Utilizes National Safety Goals when developing, implementing new processes
• Acts as a resource to all staff
• Meets the qualifications as set forth herein

Benefits

• Benefits include generous paid time off, separate sick leave, health, dental, vision, life and AD&D insurance, long-term disability and option for short-term disability, and retirement plan with employer contribution.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 251-500 employees