Quality Management Program Specialist

TX-HHSC-DSHS-DFPS • San Antonio, TX

1d • 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 from an accredited university.
• Experience related to healthcare quality management, accreditation, regulatory compliance, policy development, or performance improvement activities.
• Experience may be substituted for education.

Responsibilities

• Assists in monitoring hospital compliance with Joint Commission, CMS, and applicable state regulatory standards, including tracking compliance status and identifying gaps.
• Researches 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.
• Participates in and conducts mock tracers, mock surveys, and routine compliance audits in collaboration with the Quality Management team to assess readiness for accreditation and regulatory surveys. Assists with documentation review, staff interviews, identification of compliance gaps, and tracking of corrective actions.
• Prepares reports, dashboards, and presentations that inform quality improvement and regulatory compliance efforts for Executive Leadership, Medical Staff Executive Committee, Governing Body, and Quality Management committees.
• Assists with the coordination, documentation, and follow-up of activities related to the Medical Staff Executive Committee and Governing Body, ensuring compliance-related items are appropriately tracked and addressed.
• Serves on hospital committees and workgroups as assigned, contributing quality, patient safety, and compliance support.
• Performs other duties as assigned, including participation in disaster response, emergency preparedness, and Continuity of Operations (COOP) activities.

Benefits

• DSHS offers 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
• Number of Employees: 1,001-5,000 employees