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The Quality Manager is responsible for implementing and monitoring of quality management and quality assurance activities for the Spring Branch Community Health Center as outlined in the Quality Assurance/Quality Improvement (QAPI) plan including the establishment and improvement of clinical outcomes, making certain all healthcare services are compliant with Joint Commission Standards, Primary Care Medical Home, and performance improvement. Activities. The Quality Manager will gather, analyze, interpret, and report quality of care/performance improvement activities and initiatives at all health center sites, making policy recommendations based on these reports. He/she will advise the organization in performance improvement practices and will do so by utilizing data collection and analysis, review of third-party reports, including site visit findings. He/she will work with SBCHC leadership to educate and train all employees as to their relationship and impact on the quality management system. In addition, he/she will utilize the EMR and other IT systems as needed to identify and assess reporting capabilities and formulate pathways for obtaining data to meet needed compliance and reporting requirements, including PCMH and others. She will assist the Chief Medical Officer in the professional peer review process. This role will also assist Human Resources with employee health and immunizations tracking and compliance. QUALIFICATIONS: Bachelor’s Degree in a health care-related field or equivalent experience Master’s Degree in Hospital Administration or Public Health preferred Experience in QA systems implementation and management preferred Experience in Regulatory Audits/Surveys preferred. Familiarity with the FQHC model and reporting requirements is a plus Bilingual – English/Spanish is preferred ESSENTIAL DUTIES AND RESPONSIBILITIES: Monitors progress related to the QAPI plan. Lead the QAPI activity in conjunction with the Chief Medical Officer and guide processes that need evaluation and improvement. Keeps documentation of PIC meetings and projects/activities. Identify areas for improvement and continuously improve upon established processes through QAPI. Implement QAPI policies and procedures as needed, ensuring all clinical chart reviews and quarterly outcome assessments are conducted, monitored, and reported. Ensure that Ambulatory Care and Behavioral Health Joint Commission standards, policies, and procedures, including PCMH integrated into quality monitoring and performance improvement activities. Responsible for coordinating the Peer Review Processes. Provide training to staff and Providers to improve the quality of services and meet regulatory compliance. Monitor, analyze, and report UDS Clinical measures at least quarterly and facilitate organizational improvement. Utilize Electronic Health Records to pull data, analyze the data, and report using dashboards to drive continuous quality improvement., Create and distribute monthly scorecards for providers concerning clinical quality performance. Works in close partnership with Leadership staff and coordinates all assigned responsibilities effectively Analyzes data for patterns and trends in care delivery; works on discovering root causes as part of the analysis. Assists Human Resources with Employee Health and Immunization. Assists Compliance Officer with annual policy review process and management of policy software system. Follows and fully ensures implementation and compliance of OSHA guidelines, HIPAA guidelines, CLIA guidelines, State of Texas Regulations, PCMH standards, Joint Commission, and any other necessary safety rules. Assists nursing staff in organizing data for chronic disease registries. Attend appropriate Clinical and Operational committee meetings. Develop and implement special projects in conjunction with community partners. Stay abreast of current trends in Quality Assurance, Quality Management, and Performance Improvement, best practices, and communicate findings to train and educate staff. Attends and participates in all required agency meetings. Attend networking events to focus on building relationships with community leaders who can assist the organization in meeting set goals and objectives. Perform nursing duties commiserate with current licensure and Scope of Practice. Participates in compliance and risk management activities. Performs other duties as assigned. #J-18808-Ljbffr