GENERAL SUMMARY

This role is responsible for overseeing a variety of quality improvement programs. Leads clinical quality programs and improvements initiatives that align with organizational and strategic objectives. Utilizing improvement methodology, this role will facilitate and lead projects to achieve intended clinical or operational outcomes. Under the general guidance of the Senior Director for Quality, fosters a Zero Harm environment while promoting the principles of a High Reliability Organization.

PRINCIPAL RESPONSIBILITIES AND TASKS

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Under guidance and partnership with the leader, supports various Pay for Performance programs including, but not limited to, MHACs, QBR, PSIs and Mortality, to achieve high performance.
• Perform retrospective chart audits for key quality metrics (PPCs, PSIs and unexpected deaths) and identify improvement opportunities in clinical and/or documentation processes.
• Analyzes performance metrics in clinical procedures and operational performance to identify potential trends or root causes.
• Works collaboratively with department leadership to develop and implement the hospital level strategic plan for quality and safety.
• Partners to facilitate and implement improvements in all clinical and documentation practices in support of organizational and departmental objectives.
• Participates in regulatory activities including Joint Commission and CMS Surveys.
• Primary support and leads Leapfrog action item planning and survey completion.
• Leads or facilitates clinical improvement teams to identify, plan, implement, and sustain change for identified improvement opportunities using relevant quality tools and timelines.
• Prepares formal presentations of the quality results and presents to the appropriate committee(s).
• Responds to requests for explanation from Payors for Quality of Care letters or clinical concerns.
• Represents the team and offers quality improvement expertise in committee meetings as needed.
• Manages and supervises quality team members including hiring, performance management, evaluations, directs and reviews work, and terminations.
• Promotes an engaged, healthy work environment for team members by establishing a climate of support, growth, challenge, and development of all team members
• Develops and recommends department operating budget and manages resources according to approved budget.
• Performs other duties as assigned.

All your information will be kept confidential according to EEO guidelines.

Compensation:
Pay Range: $44.76 - $67.19
Other Compensation (if applicable):
Review the 2025-2026 UMMS Benefits Guide

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