Quality Improvement Specialist

TX-HHSC-DSHS-DFPS • San Antonio, TX

2d • $4,583 - $5,372 • Onsite

About The Position

Under the supervision of the Director of Quality Management, the Program Specialist I in Quality Management (QM) assists in coordinating the compliance, evaluation, and continuous improvement of healthcare services and programs within the hospital. This position supports hospital compliance with Joint Commission, Centers for Medicare & Medicaid Services (CMS), and applicable state and departmental regulatory standards. Primary responsibilities include researching regulatory standards, developing and maintaining hospital policies and procedures, conducting routine audits and mock tracers, supporting mock survey activities, and assisting with the development and monitoring of Plans of Correction (POCs) for identified compliance gaps. The Program Specialist I works closely with the Quality Management team, hospital leadership, medical staff, and operational departments to support accreditation readiness and ongoing quality improvement efforts. This position works under limited supervision with latitude for initiative and independent judgment within established guidelines.

Requirements

• Knowledge of or experience with Joint Commission and CMS accreditation standards and healthcare regulatory requirements.
• Knowledge of policy and procedure development, revision, and document control processes.
• Knowledge of performance improvement and quality management principles.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Word, Excel, and PowerPoint.
• Skill in preparing reports and tracking compliance and corrective actions.
• Ability to work collaboratively with multidisciplinary teams.
• Ability to interpret and apply regulatory requirements in operational and clinical settings.
• Ability to analyze data and present findings clearly and accurately.
• Ability to conduct or participate in mock tracers, mock surveys, and compliance audits in a hospital or clinical environment.
• Bachelor’s degree or higher from an accredited college or university.
• Minimum of two years of professional experience in a healthcare setting.
• Minimum of two years of experience in healthcare quality management, accreditation, regulatory compliance, performance improvement, policy development, nursing, social work, public health, healthcare administration, infection prevention, or risk management.

Responsibilities

• Monitors hospital compliance with Joint Commission, CMS, and applicable state regulatory standards, by conducting regulatory reviews, tracking compliance activities, identifying gaps, and supporting ongoing survey readiness efforts.
• Researches, interprets, and applies Joint Commission, CMS, and state regulatory requirements and develops, revises, and maintains hospital policies and procedures to ensure alignment with current standards and regulatory expectations.
• Conducts mock tracers, mock surveys, and compliance audits to evaluate accreditation readiness, assess adherence to regulatory requirements, identify opportunities for improvement and monitor implementation of corrective actions.
• Collects, analyzes, and reports quality, patient safety, infection prevention, regulatory compliance, and performance improvement data; develops dashboards, trend analyses, and recommendations to support organizational decision-making, and performance improvement initiatives.
• Coordinates the development, implementation, and monitoring of Plans of Correction (POCs), corrective action plans, and accreditation evidence collection and regulatory readiness activities; collaborates with hospital departments to ensure timely resolution of identified compliance gaps.
• Assists with the coordination, documentation, and follow-up of hospital committees and workgroups, ensuring quality, patient safety, accreditation, and compliance related activities are appropriately tracked and addressed.
• Participates and leads quality improvement activities, including Root Cause Analysis, Failure Mode and Effect Analyses, patient tracers and performance improvement projects designed to improve patient safety, quality of care, regulatory compliance and organization performance.
• Performs other duties as assigned, including participation in disaster response, emergency preparedness, and Continuity of Operations (COOP) activities.

Benefits

• insurance coverage and other benefits available through the State of Texas Group Benefits Plan administered by the Employee Retirement System of Texas (ERS)

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level