QA/QI Manager

The QA/QI Manager participates in ongoing Quality Assurance/Quality Improvement (QA/QI) activities under the direction of the Executive Director/CEO and the Medical Director/Chief Medical Officer. The QA/QI Manager is responsible for collection, analysis, and reporting of data to support quality management objectives:

1. Monitor and evaluate patient care activities to identify trends and opportunities for improvement.
2. Develop evaluation tool that will produce quantitative and qualitative data and findings to validate compliance by vendors.
3. Monitor and evaluate patient satisfaction surveys: a. process data collection and analysis of data by internal staff and outside consultants; and, b. develop written reports of findings and recommendations for executive team, program managers and Board of Directors' Committees, as directed.
4. Conduct audits of electronic and paper clinical case records for documentation to support Medicaid billing invoices.
5. Initiate and lead the QA/QI committee in organizational regulatory compliance, evidence based care and standards of practice and clinical reimbursements; and, initiate and oversee the planning and development of policy and procedure for high risk areas.
6. Investigate patient and provider complaints and grievances.
7. Monitor and evaluate use of appropriate patient triage.
8. Monitor and evaluate contract compliance for base hospitals, pre-hospital care providers and trauma centers.
9. Provide overall direction necessary to ensure clinical services are provided in accordance with standards established through State and Federal regulations and accreditation standards.
10. Provide strategic oversight of proactive and reactive safety activities including root cause analysis and failure mode effects analysis in regards to the facilitation of process, planning, implementation and evaluation of effectiveness of process changes.
11. Assess entity compliance with accreditation standards and regulations related to clinical care in collaboration with Shalom's management team and clinical staff.
12. Identify areas of vulnerability and directs the development of strategies to enhance compliance.
13. In conjunction with the Medical Director/CMO and Shalom's management team, direct and coordinate safety/quality performance improvement initiatives.
14. In collaboration with clinical staff, participates in monitoring, reporting and improvement activities related to clinical guidelines, healthcare quality/safety initiatives, accreditation and regulatory requirements.
15. Lead, facilitate, consult and recommend process improvement initiatives to comply with major improvement initiatives, assisting in the maximizing scores for publicly reported data and benchmarking.
16. Work effectively in multi-disciplinary teams, leading and facilitating, to move the organization to new areas of excellence.
17. Assist in writing grant proposals for additional funding.
18. In collaboration with the Medical Director/CMO and Shalom's management team, responsible for assessing clinical staff education needs and competency checks.

Leadership/Supervisory Duties and Responsibilities:

1. Lead the organization, along with the Executive Director/CEO, Medical Director/CMO, Finance Director/CFO, Human Resources/Operations Director and Patient Care Director in supporting the participation of all Shalom staff in applying the principles of performance improvement/continuous quality improvement refining existing processes and enhancing the effective utilization of corporate resources.
2. Maintain a high level of communication with staff through participation in regularly scheduled meetings.
3. Assist with other projects or duties in conjunction with the Executive Director/CEO, Medical Director/CMO, Finance Director/CFO, Human Resources/Operations Director, Patient Care Director, and IT Manager.
4. Ensure corporate compliance with all applicable quality and accreditation standards.

Education & Qualification Requirements: Graduate of an accredited School, College or University and possess at least one of the following combinations of education and experience:

1. Bachelors in public health, hosptial administration, or a related field, plus four (4) years' QA/QI experience in a health care environment; OR
2. Masters of Public Health (MPH), plus two (2) years' QA/QI experience in a health care environment; OR
3. Masters of Social Work (MSW), plus two (2) years' QA/QI experience in a health care environment.
4. Patient Centered Medical Home (PCMH) experience/knowledge, a plus.
5. Must have experience in Quality Improvement, Quality Assurance, and Risk Management in a health care environment.

Knowledge, Skill, Ability and Work Difficulty:

• Working knowledge of QA/QI to independently make appropriate decisions that impact Shalom Health Care Center's accreditation and financial well-being.
• Able to develop and maintain effective interpersonal relations, maintain confidentiality of data, information, and activities,
• Able to perform detailed, concentrated work with limited supervision.
• Demonstrates statistical thinking skills, including knowledge and use of simple statistics, process variation and data analysis in order to provide data analysis.
• Bilingual – English/Spanish, a plus.
• Working knowledge of Microsoft platforms (MS Word, Excel, PowerPoint, etc.).
• Working knowledge of Electronic Medical Record (EMR) software (e-Clinical Works, preferred).
• Excellent interpersonal skills.
• Demonstrate leadership, organization and communication expertise.
• Excellent verbal and written communication skills.

Physical Demands and Work Environment:

• Pass a physical examination after being offered employment and a health assessment annually, thereafter.
• Clear annual TB, influenza, and other communicable disease testing.
• Perform under pressure of patients and clinic staff needing assistance to meet deadlines.
• Exposure to indoor office florescent lights.
• Exposure to computer monitor.
• May be required to stand or sit for prolonged time period.
• May be required to bend stoop, kneel, pull, climb, reach, lift, and perform repetitive movements of the upper extremities.
• Requires normal hand-eye coordination and dexterity.
• Requires normal vision capability.
• Distinguish letter, numbers or symbols.
• May be exposed to small amounts of hazardous materials.
• May be exposed to unsanitary conditions in some home settings.
• May be exposed to high crime areas within the service area community.
• Exposure to weather and temperature extremes.