QA RN)

Bethel Family Clinic•Bethel, AK

13d•Hybrid

About The Position

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.

Requirements

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, or 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

Nice To Haves

QI/QA 2-3 years Direct Experience
Experience in a FQHC, tribal health organization, or safety‑net setting
Experience with HRSA UDS reporting
Experience with HRSA OSVs
Experience with 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)

Responsibilities

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
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
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
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
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
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, and 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
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
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
Prepare quality, compliance, and risk management reports for leadership, Quality Committee, and Board of Directors (as required)
Participate in quality, compliance, and risk management committees
Maintain accurate documentation and reporting records
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