Director Of Quality Improvement

Job Title: Director of Quality Improvement

Department: Quality Improvement

Reports To: Chief Clinical Officer

FLSA Status: Non-Exempt

Full-time/Part-time: Full-time

Position Summary: The Director of Quality Improvement will be responsible for oversight of Quality programs at Wesley Community and Health Centers. The Director of Quality Improvement will support the Clinic and the Operations department in a manner that is consistent with overall clinic strategies, policies and procedures and demonstrate a relentless commitment to providing data, follow-up and innovations necessary to consistently improve the quality and effectiveness of Wesley’s services.

Essential Duties and Responsibilities: To perform this job successfully, an individual must be able to perform the following satisfactorily; other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Under the direction of the Chief Medical Officer, the Director of Quality Improvement will play an essential role in the coordination, implementation and evaluation of daily quality operations.
• Participates in multiple committees and process improvement teams within the company. Recommends policy and procedure development and revisions.
• In conjunction with the Chief Medical Officer and HRSA standards, defines core clinical performance measures and provides oversight for the data collection and reporting system(s).
• Collaborates with the Chief Medical Officer and Quality Committee to identify and develop Quality Improvement opportunities and initiatives. Establishes and maintains the annual quality activity calendar.
• Develops, implements, and ensures that policies and procedures for standard patient care are maintained at WCHC utilizing the Plan-Do-Study-Act (PDSA) model and oversees adherence to regulatory standards for Quality Improvement.
• Oversees progress of all Quality Improvement projects and develops succinct and comprehensive reports detailing Quality Improvement activities, including periodic reporting of performance data to the Board of Directors (BOD), senior management, staff and financial grantees.
• Collaborates with the Operations Team to ensure patient objectives are being met and complaints are identified and resolved in a timely manner.
• Attend meetings with health plans and implement strategies to close care gaps.
• Collaborates with Chief Financial Officer to ensure back office is documenting and coding to appropriately capture the work that is completed.
• Serves as Project Manager for the accreditation and recognition of the National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH).
• Serves as Project Manager of the yearly Uniform Data Submission (UDS) for clinical and demographic information.
• Serves as contributor for the yearly Health Resources & Services Administration (HRSA) Grant.
• Communicate with management of back and front office regarding patient satisfaction and complaints to address these effectively.
• Maintains a knowledge base of HEDIS and Title X requirements and implementing clinical performance methods to improve HEDIS and Title X performance.
• Assists in grant (federal, state and local) application processes.
• Represents WCHC at regular QI meetings for the Arizona Alliance for Community Health Centers.
• Maintains positive community engagement within the WCHC service area.
• Participates in continuing education activities and professional development for professional growth, licensure and certification requirements.
• Travels as required to all clinic locations.

Additional Responsibilities:

• Promotes and believes in Wesley Community Center's mission statement, “Together we empower positive change”.
• Ability to relate to the public regardless of ethnic, religious, gender identification, sexual orientation or economic status.
• Familiar with the local community and have knowledge of services and resources that are available.
• Competent in computer software such as spreadsheets, word processing and other programs that are necessary for performing the required tasks.

Competencies: To perform the job successfully, an individual should demonstrate the following.

Communications - Exhibits good listening and comprehension. Expresses ideas and thoughts in written form. Expresses ideas and thoughts verbally. Keeps others adequately informed. Selects and uses appropriate communication methods.

Problem Solving- Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem-solving situations; uses reason even when dealing with emotional topics.

Project Management- Develops project plans; coordinates projects; communicates changes and progress; completes projects on time and budget; manages project team activities.

Quality Management- Looks for ways to improve and promote quality; demonstrates accuracy and thoroughness.

Strategic Thinking - Develops strategies to achieve organizational goals; understands organization's strengths & weaknesses; analyzes market and competition; identifies external threats and opportunities; adapts strategy to changing conditions.

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

Education/Experience – Bachelor’s Degree in Nursing or a related field or equivalent years of related experience. Or a Master’s Degree in Nursing, Business, or a related field – replaces 3 years of experience. 5 years of experience in a health care delivery organization, such as a community health clinic, managed care organization, or a hospital environment. Knowledgeable of Medicaid and/or Medicare programs. Knowledge of CMS regulatory requirements. Knowledgeable of NCQA, HRSA, HEDIS, Title X, and CAHPS requirements. Knowledgeable of current trends in Quality Improvement in managed health care. Demonstrated leadership and organizational skills. Bi-lingual in English/Spanish preferred.

Language Ability – Read, analyze and interpret complex documents. Respond effectively to sensitive inquiries. Write speeches and articles using innovative techniques. Make persuasive presentations on complex topics to management, public groups and/or boards of directors.

Mathematical Ability – Work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability – Define problems, collect data, establish facts and draw valid conclusions. Interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

Computer Skills –MS Office and MS Office 365

Certificates and Licenses

• Registered Nurse, active and in good standing in the State of Arizona.
• CPR & BLS certification, or be willing to acquire on the job.
• Fingerprint clearance card, or ability to obtain a clearance card.

Supervisory Responsibilities – This position is responsible for overseeing multiple program areas. Must be comfortable supervising up to 10 individuals.

Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.The noise level in the work environment is usually moderate.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel and talk or hear. The employee is frequently required to stand; walk; sit; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee is occasionally required to climb or balance and taste or smell. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor.

WCHC’s Expectations of all Employees

• Adheres to all WCHC Policies and Procedures
• Conducts self in a manner that represents WCHC’s Values at all times
• Maintains a positive and respectful attitude with all work-related internal and external contacts
• Communicates regularly with supervisor about Departmental and WCHC concerns
• Consistently reports to work on time, prepared to perform the duties of the position
• Meets productivity standards and performs duties as workload necessitates
• Actively participates in all required trainings
• Empowered to provide outstanding service to all customers