Quality Improvement Director

Contentnea Health•Snow Hill, NC

About The Position

The Quality Improvement Director provides strategic leadership, oversight, and coordination for organizational quality initiatives. The role designs, implements, and evaluates quality programs to support safe, patient-centered, equitable, and efficient care; leads data-driven improvement efforts; and supports regulatory reporting and compliance. The Director oversees the Quality Improvement department and its staff, budget, performance, and projects, and represents the department at senior management meetings. The Director leads the organization’s Quality Improvement Program, establishes annual goals and performance benchmarks, develops dashboards and data tools, and works with clinical care teams and leaders to apply standardized best practices. The position oversees quality data collection, analysis, sharing, and external reporting, including UDS clinical measures and applicable federal and state requirements. It also supports HRSA reviews and maintains compliance with Federal Tort Claims Act requirements, including leading the annual deeming and redeeming application process. The role oversees participation and performance in value-based care and quality incentive plans, and maintains alignment with Patient-Centered Medical Home standards. The Director manages NCQA reporting and PCMH recognition activities, serves as the PCMH subject matter expert and project manager, coordinates improvement work, and ensures staff training and required documentation are maintained. The position also manages departmental staff, including hiring, performance appraisals, discipline, and termination procedures.

Requirements

Bachelor’s degree in Nursing.
Current Registered Nurse licensure in good standing with the North Carolina Board of Nursing.
Advanced understanding of quality improvement theory and methodology.
Understanding of evidence-based practice.
Understanding of state and national priorities for patient safety and population health as determined by HRSA, DHHS, and other entities.
Understanding of regulatory, recognition, and compliance standards, including FTCA, PCMH, and HRSA.

Nice To Haves

Progressive experience leading quality improvement activities.
Experience leading staff.

Responsibilities

Oversee the activities of the Quality Improvement department.
Lead the development, implementation, and evaluation of the organization’s Quality Improvement Program.
Identify opportunities to support quality improvement through evaluation, testing, or integration of EHR functionality and other health information technology systems.
Summarize and share clinical quality data with the Board, leadership, and staff to inform decisions and improvement priorities.
Promote adoption of standardized best practices and lessons learned across departments and care teams using communication tools, workflows, meetings, events, and training.
Facilitate Quality Improvement Committee meetings and ensure documentation, follow-up, and progress tracking.
Establish annual quality improvement goals, work plans, and performance benchmarks aligned with strategic priorities.
Develop dashboards and data tools to share performance results with leadership and staff.
Collaborate with and guide clinical care team members in establishing quality improvement processes.
Lead or participate in quality improvement work teams and coach care teams in patient-centered practices and healthy patient outcomes.
Research external organizations, participate in training, and work with partners, consultants, and experts to guide quality improvement efforts.
Assess staff education, training, and technical assistance needs and facilitate support to ensure compliance with quality improvement efforts.
Use existing data systems to identify areas for organizational quality improvement.
Oversee organizational data submission and sharing with external entities in collaboration with other departments.
Follow HRSA regulations for data collection and reporting and health plan incentive requirements.
Consider data governance when changes are made to EHR or other IT systems.
Monitor Federal Tort Claims Act requirements and health center compliance.
Lead the annual FTCA deeming and redeeming application process and ensure required evidence and documentation are completed and submitted accurately.
Ensure accurate, timely reporting of UDS clinical measures and other federal and state quality requirements.
Participate in HRSA reviews and responses with organizational leaders.
Administer electronic Value-Based Care and Quality Incentive Plan platforms.
Partner with leadership to determine participation priorities and oversee QI and clinical participation in contracted VBC and QIPs.
Monitor performance in value-based care and incentive plans and share performance data with leadership.
Ensure ongoing alignment with PCMH standards, manage NCQA reporting, and serve as PCMH project manager.
Lead annual PCMH report submissions to maintain recognition at each recognized site and maintain documentation and policies for audits, accreditation, and regulatory compliance.
Ensure new hires are trained in PCMH processes, policies, and workflows, including care coordination, team-based care, access, patient experience, and satisfaction.
Maintain knowledge of NCQA and PCMH standards and serve as the subject matter expert; review processes, policies, and systems to ensure alignment with current standards.
Use data to drive continuous improvement in clinical quality, patient experience, and cost and utilization outcomes.
Report PCMH performance to leadership to inform resource allocation and performance improvement priorities.
Coordinate PCMH improvement activities with staff and leadership.
Provide overall management and direction to departmental staff.
Oversee development and maintenance of the departmental budget, monitor budget compliance, and address issues.
Delegate departmental duties and responsibilities and participate in high-priority projects and activities.
Represent the department at senior management meetings.
Prepare departmental policies and procedures and communicate senior management directives.
Monitor departmental performance against company standards and address issues.
Direct departmental performance and provide instructions on completing tasks and responsibilities.
Prepare and conduct performance appraisals for immediate staff.
Conduct hiring, disciplinary, and termination procedures.