Summary
Job Summary
Responsible for strategic leadership, oversight, and coordination of ambulatory quality improvement, regulatory compliance, accreditation readiness, patient safety initiatives, provider quality programs, and performance improvement activities across the Neighborhood Health Clinics (NHC). Ensures the UMC Clinic alignment with organizational goals, regulatory requirements, accreditation standards, and value-based care initiatives while fostering a culture of continuous improvement, high reliability, patient-centered care, and operational excellence. Collaborates closely with the Director Managed Care Performance, Director of Outpatient Clinical Documentation Improvement (CDI), Chief of Community Medicine, clinic operational leadership, clinic leadership, medical staff leadership, and other stakeholders to support the goals of the Clinic Performance and Population Health Department.
Skills
1. Ability to evaluate processes and provide recommendations for process improvement.
2. Knowledge of Joint Commission, CMS, and regulatory accrediting agency standards to assure compliance.
3. Strong communication skills, both written and verbal.
4. Ability to understand, use and teach the principles of performance improvement.
5. Ability to evaluate quality issues and present data to other professionals in a clear concise manner.
6. Ability to proficiently utilize analytical assessment and creative problem solving.
7. Ability to use critical thinking skills to conduct research and utilize interpersonal and problem-solving skills.
8. Ability to organize, delegate, implement, and evaluate effectiveness of processes.
9. Ability to work with Electronic Medical Records and use a computer and related software applications.
10. Ability to interview and work in teams.
11. Knowledge of report writing software and working with Microsoft Office.
12. Knowledge of hospital systems and organizational relationships.
13. Knowledge of Six Sigma methodologies to address performance improvement processes.
14. Knowledge and skills to develop new methods and approaches to maintain or increase Clinical Measure compliance. Requires a wide range of concepts, principles, and practices in the healthcare profession.
15. Knowledge of health care trends and proven solutions for improving patient care.
Work Experience
Five years of management/supervisory experience is required. Strong professional nursing experience with knowledge in areas of Quality Assurance, Performance Improvement, and Regulatory Compliance is required, preferably in an outpatient setting.
License/Registration/Certification
Current and active license to practice as a Registered Nurse in the state of Texas is required.
Certified Professional in Healthcare Quality (CPHQ) is required within two years of being in the position.
Education and Training
Bachelor degree in Nursing is required. Master degree is preferred.