Quality Improvement Director

Company Overview

Contentnea Health is a Community Health Center providing comprehensive medical, dental and behavioral health services for members of our communities in Greene, Pitt and Pamlico counties in eastern North Carolina.    

Job Summary

Provides strategic leadership, oversight, and coordination of all organizational quality initiatives, including designing, implementing and evaluating quality programs to ensure delivery of safe, patient-centered, equitable, and efficient care, leads data-driven improvement efforts, and supports regulatory reporting and compliance with standards.  

Responsibilities and Duties

1. Oversees the Quality Improvement (QI) department activities.
   1. Leads the development, implementation, and evaluation of the organization’s Quality Improvement Program.
   2. Identifies opportunities to support QI efforts through evaluation, testing, and/or integration for electronic health record (EHR) functionality and other Heath Information and Technology (HIT) systems.
   3. Summarizes and shares clinical quality data with the Board, key leadership, and staff to inform decision-making and priorities for improvement.
   4. Champions the adoption of standardized best practices and lessons learned across disciplines and departments at the care team level and at the organizational level using communication tools, published workflows, staff meetings, events and trainings.
   5. Facilitates QI Committee meetings and ensures documentation, follow-up, and progress tracking.
   6. Establishes annual QI goals, work plans, and performance benchmarks aligned with strategic priorities.
   7. Develops dashboards and data tools to share performance results with leadership and staff.
2. Collaborates with and guides clinical care team members to establish QI processes through the organization.
   1. Leads or participates in work teams related to QI and functions as a coach to support care team in building, fostering patient-centeredness and healthy patient outcomes.
   2. Researches external organizations and participates in training opportunities, and works with partners, consultants and experts to guide QI efforts.
   3. Assesses the need for and facilitates education, training, and technical assistance for staff to ensure compliance with QI efforts.
   4. Uses existing data systems to identify areas in need of quality improvement across the organization.
3. Oversees organizational data submission and sharing to external entities in collaboration with other departments as needed.
   1. Follows regulation on data collection and reporting structure as defined by the Health Resources and Services Administration (HRSA) and health plan incentives.
   2. Approaches changes to the EHR or other IT systems with consideration to data governance.
   3. Monitors Federal Tort Claims Act (FTCA) requirements and the health center’s compliance.
   4. Leads the annual FTCA deeming and redeeming application process and ensures all required evidence and documentation are completed and submitted accurately.
   5. Ensures accurate and timely reporting of UDS clinical measures and other federal/state quality requirements.
   6. Participates in HRSA review and response with organization leaders.
   7. Acts as administrator for electronic Value-Based Care (VBC) and Quality Incentive Plans (QIP) platforms.
   8. Partners with key leadership to determine participation priorities.
   9. Oversees QI and clinical participation in contracted VBC and QIPs.
   10. Monitors performance with VBC and incentive plans; shares performance data with key leadership.
4. Ensures ongoing alignment with Patient-Centered Medical Home (PCMH) standards, manages The National Committee for Quality Assurance (NCQA) reporting and serves as PCMH project manager.
   1. Leads annual submission of PCMH report to maintain recognition for each recognized site and maintains documentation and policies needed for audits, accreditation, and regulatory compliance.
   2. Ensures all new hires are trained in PCMH processes, policies, and workflows, including care coordination, team-based care, access, patient experience and satisfaction.
   3. Maintains current knowledge of NCQA/PCMH standards and serves as the subject matter expert. Analyzes and reviews processes, policies, and systems on an ongoing basis to ensure they are aligned with current and updated PCMH standards. 
   4. Uses data to drive continuous improvement in clinical quality, patient experience and cost/utilization outcomes.
   5. Reports PCMH performance to leadership to inform resource allocation and prioritize performance improvement activities.
   6. Coordinates PCMH improvement activities with staff and leadership.
5. Provides overall management and direction to departmental staff.​​​​​​​​​​​​​​
   1. Oversees the development and maintenance of the departmental budget; monitors ongoing budgetary compliance and addresses problems as needed.
   2. Delegates departmental duties and responsibilities; participates in high priority special projects and activities.
   3. Represents the department at all senior management meetings.
   4. Prepares departmental company policies and procedures and conveys all senior management communications and directives.
   5. Monitors departmental performance using company performance standards and addresses issues as needed.
   6. Directs departmental performance and provides specific instructions  on completion of tasks/responsibilities.
   7. Prepares and conducts performance appraisals for immediate staff.
   8. Conducts hiring, disciplinary, and termination procedures.

Qualifications and Skills

Bachelor Degree in Nursing. Current licensure as a Registered Nurse in good standing with the NC Board of Nursing. Possesses advanced understanding of quality improvement theory and quality methodology, evidence-based practice, state and national priorities for patient safety and population health as determined by HRSA, DHHS, and other entities, and regulatory, recognition and compliance standards, such as FTCA, PCMH, and HRSA. The ideal candidate will have progressive experience in leading quality improvement activities and in leading staff.