Quality Program Manager

JOB DESCRIPTION:

The Quality Program Manager is responsible for the development, implementation, and operational execution of the organization’s Quality Improvement/Assurance (QI/QA) Program in alignment with HRSA Health Center Program requirements. This role serves as the central point of coordination for quality improvement activities across the organization leading continuous quality improvement (CQI) activities across clinical, dental, behavioral health, and key support services, ensuring that performance data is translated into actionable improvement initiatives that enhance patient outcomes, access to care, and patient experience.

The Quality Program Manager works in close collaboration with the Medical Director, Clinic Director, Senior Clinical Reporting & EHR Systems Analyst, the Compliance and Risk Officer, and the Safety Officer to support a coordinated, data-driven approach to quality, patient safety, and regulatory compliance. The Quality Program Manager reports to the Director of Clinical Operations with a dotted-line reporting relationship to the Compliance and Risk Officer.

Duties, responsibilities, and activities may change at any time with or without notice.

Job Qualifications and Skills:

• Strong analytical, problem-solving, and organizational skills.
• Ability to translate complex data into actionable strategies and improvement initiatives.
• Knowledge of healthcare quality improvement principles, methodologies (e.g., PDSA), and performance measurement.
• Knowledge of clinical quality measures, patient safety concepts, and performance improvement standards.
• Familiarity with regulatory requirements impacting quality programs, including HRSA, UDS, and other applicable programs.
• Skill in data interpretation, trend analysis, and performance monitoring.
• Ability to establish and maintain effective collaborative working relationships across departments and disciplines.
• Strong written and verbal communication skills, including facilitation of meetings and presentation of data to leadership.
• Demonstrated ability to manage multiple priorities, adapt to change, and work independently and as part of a team.
• Demonstrate cultural sensitivity and experience or interest in working with underserved populations.
• Strong proficiency in Microsoft Office (Excel, Word, PowerPoint) and data reporting tools.
• Commitment to patient-centered care, continuous improvement, and organizational values, including confidentiality and ethical practices.

Education and Experience Required:

• Bachelor’s degree in healthcare administration, public health, nursing, or related field required.
• Minimum of 3–5 years of experience in healthcare quality improvement, performance improvement, or clinical operations.
• Experience with data analysis, dashboards, and performance reporting.
• Experience working in a healthcare setting required; FQHC or similar environment preferred.

Education and Experience Preferred:

• Master’s degree or advanced training in a health-related field preferred.
• Experience with an FQHC, FQHC Look-Alike, or similar organization preferred.
• Certification in quality or performance improvement (e.g., CPHQ) preferred.
• Experience with Electronic Health Record systems (e.g., Epic/OCHIN) preferred.
• Knowledge of HRSA, UDS, Ryan White/HAB, or value-based care programs preferred.

JOB RESPONSIBILITIES (includes but not limited to):

1. Quality Program Oversight & Governance

• Provide operational leadership for the organization’s Quality Improvement Program and associated initiatives.
• Develop, implement, and maintain the organization-wide QI/QA Plan, inclusive of medical, dental, and behavioral health services.
• Ensure integration of quality improvement activities across clinical and key support services to improve patient outcomes, access to care, and patient experience.
• Lead the annual evaluation of the QI/QA Program, including effectiveness, outcomes, and opportunities for improvement.
• Ensure QI activities meet HRSA, UDS, and other applicable regulatory and program requirements.
• Promote a culture of continuous quality improvement and patient safety across the organization.
• Standardize QI processes, documentation, and reporting tools across departments.
• Ensure that quality improvement activities result in measurable improvement in performance metrics and patient outcomes.

2. Performance Measurement & Data Utilization

• Collaborate with the Senior Clinical Reporting & EHR Systems Analyst to define, validate, and monitor clinical quality measures and operational performance indicators.
• Translate performance data (e.g., UDS, clinical quality measures, patient experience data) into actionable insights, improvement strategies, and organizational priorities for leadership and care teams.
• Incorporate relevant performance indicators from pharmacy and enabling/support services to support whole-person, patient-centered care.
• Monitor performance trends at the organizational, departmental, and provider levels to identify gaps and opportunities for improvement.
• Lead analysis and performance monitoring of quality incentive programs, using results to inform improvement priorities, reporting, and organizational strategy.
• Monitor and analyze performance across HRSA, regulatory, and payer-based quality programs (e.g., UDS, Ryan White/HAB, FTCA clinical risk management, and value-based initiatives) to inform reporting, compliance, and continuous improvement efforts.
• Monitor and analyze performance of high-risk care coordination processes (e.g., referral tracking, diagnostic test follow-up, and ED/hospitalization follow-up), including those aligned with FTCA clinical risk management expectations.
• Support development and maintenance of dashboards and reports to track progress toward quality goals.
• Stratify data, as appropriate, to identify disparities in care and outcomes across patient populations.

3. Continuous Quality Improvement (CQI) Implementation

• Lead and facilitate QI initiatives using structured methodologies (e.g., PDSA cycles).
• Support clinical and operational teams in designing, implementing, and evaluating improvement projects.
• Collaborate with pharmacy and support service leaders to align improvement initiatives with clinical outcomes and access to care.
• Monitor implementation of improvement initiatives and ensure timely completion of action plans.
• Ensure consistent documentation of QI activities, interventions, and outcomes.
• Ensure accountability for progress on quality initiatives between CQI meetings.
• Align QI initiatives with organizational strategic priorities and performance goals.
• Collaborate with the Director of Clinical Services and other operational leaders to support performance improvement efforts, while operational accountability for staff performance and workflow execution remains within clinical operations leadership.

4. CQI Committee & Organizational Reporting

• Coordinate and manage the quality-focused Continuous Quality Improvement (CQI) Committee, including agenda development, meeting facilitation, and documentation of minutes.
• Maintain and monitor the QI work plan and reporting calendar to ensure timely completion of deliverables.
• Prepare and contribute to quarterly and annual quality reports for leadership and the Board of Directors.
• Ensure QI documentation is organized, accessible, and audit-ready.

5. Patient Experience & Feedback Integration

• Oversee the administration, analysis, and reporting of patient satisfaction surveys.
• Monitor trends in patient feedback, complaints, and grievances (in collaboration with Compliance/Risk).
• Incorporate patient experience data into QI initiatives and organizational improvement efforts.

6. Integration with Risk Management & Peer Review

• Collaborate with the Compliance and Risk Officer to support clinical risk management and peer review activities, including data collection, preparation, and trend analysis.
• Assist in the aggregation and analysis of incident reports, peer review findings, and clinical risk data to identify patterns and opportunities for improvement.
• Incorporate findings and trends from risk, compliance, and peer review activities into quality improvement initiatives.
• Support development and monitoring of corrective action plans resulting from clinical reviews and investigations.
• Maintain appropriate confidentiality and ensure activities are conducted in alignment with organizational policies and regulatory requirements.
• Activities related to clinical risk management and peer review are performed under the direction of the Compliance and Risk Officer.

7. UDS & Regulatory Quality Alignment

• Utilize UDS and other regulatory reporting data to inform QI priorities and organizational performance improvement.
• Ensure alignment of quality improvement activities with applicable regulatory, accreditation, and payer requirements.
• Collaborate with the EHR Systems Analyst and Grants team to ensure data accuracy, integrity, and alignment with reporting requirements.
• Provide guidance to clinical and administrative staff on quality measures, documentation standards, and performance expectations.

8. Staff Engagement, Training & Support

• Provide education and training to staff on QI principles, performance measures, and improvement methodologies.
• Support department leaders and clinical teams in understanding and improving performance metrics.
• Promote accountability for performance outcomes across clinical teams.
• Serve as a resource to leadership and staff on quality-related initiatives and expectations.

Supervisory Responsibilities:
This position does not have direct supervisory responsibilities but may provide functional leadership, guidance, and coordination across departments related to quality improvement activities.

Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

*"Only applicants who clear the custom questions will be considered."*

Pay: $70,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Loan repayment program
• Paid time off
• Parental leave
• Retirement plan
• Tuition reimbursement
• Vision insurance

Application Question(s):

• I certify that I am not now, nor have I ever been, excluded, suspended or otherwise ineligible for participation in federal or state health care programs.

Work Location: In person