Quality Manager
Job Details
Family Health/La Clinica-Stevens Point - Stevens Point, WI

Under the direction of the COO, this position is responsible for the oversight of a Quality Assurance/Quality Improvement (QA/QI) program at all Family Health La Clinica (FHLC) locations. Further, this position specifically cultivates an understanding of fully integrated healthcare: behavioral health, medical and dental services. Works closely with the COO and service line leaders to ensure continuous quality improvement, with special attention to interaction and integration between clinical service lines.  As a member of the leadership team, this position works alongside fellow members in development and implementation of policies, procedures, and process improvement to accomplish FHLC goals, build a culture consistent with FHLC’s mission, vision, and values, while complying with internal and external policies and laws.  identifying, implementing, monitoring, and evaluating the overall clinical quality and system wide QA/QI program at all FHLC locations.  Collects and analyzes data and assists with performance audits to identify improvement opportunities. Oversees the organizations Risk and Emergency Preparedness planning.  Recommends action plans to address quality concerns and outcomes.

  • Collaborates with the FHLC leaders to develop a comprehensive QA/QI Performance Management Plan, in accordance with HRSA Health Center Program Requirements and industry standard best practices.
  • Chairs the FHLC QA/QI Quality Oversight Committee. Attends and contributes to other departmental QA/QI Meetings.
  • In conjunction with other members of the FHLC Leadership Team, contributes to development of an operational plan that establishes clearly defined performance standards, metrics and workflows that can be tracked against timelines to evaluate the organization's performance at all times.
  • Assists the COO to monitor staff’s efforts to ensure compliance with HRSA Health Center Program Requirements including, but not limited to:
    • Credentialing and Privileging
    • Hospital / ER Tracking
    • Referral Tracking
    • Diagnostic Tracking
    • Peer and Medical Record Review
    • Routine and regular reporting of UDS Clinical Performance Measures
  • Assists with report development, as it relates to FHLC performance initiatives and reporting of UDS Clinical Performance Measures.
  • Supports the team focus in providing excellent patient care; Proactively acts to continuously improve and monitor patient satisfaction.  Manages the patient experience.
  • Participates in the critical analysis of the organization’s data for existing clinical outcome measures, while working closely with FHLC Leadership to develop additional performance measures. 
  • Imbeds quality improvement infrastructure and methods into all clinic operations.
  • Coordinates PDSA cycle efforts for the organization including collecting and analyzing data, summarizing results, and presenting significant findings to Leadership and the Quality Oversite Committee.
  • Presents results of improvement efforts, ongoing performance measures and recommends actions plans to the FHLC Leadership Team.
  • Educates staff regarding the CQI principals and quality improvement best practices.
  • Participates in training of staff on HRSA FQHC Requirements. 
  • Meets with clinical teams about outcomes data to discuss implications for clinical practices and identifies areas needing improvement.
  • Coordinates needs and training related to achieving compliance with the 19 Bureau of Primary Health Care (BPHC) program requirements.
  • Provides support to other Risk Management programs.
  • Focus on FHLC cost of services, quality of services, access to services, and attention to root causes of poor health.
  • Contribute to the development of FHLC’s strategic plan and support. Implementation/operation as new opportunities arise.
  • Responsible for creating, updating, and maintaining policies and procedures related to quality, ensuring adherence to Federal and State Regulatory requirements, as well as industry standard best practices.
  • Maintains a comprehensive understanding of HRSA Health Center Program Requirements, as it relates to the current scope of services and organizational performance, and ensures QA/QI efforts comply with regulatory and accreditation standards.
  • Performs all responsibilities, in accordance with organizational policies and procedures, and ensures compliance with HIPAA Privacy and Security Standards. Promotes a culture of high performance and continuous improvement that values learning and a commitment to quality.
  • Provides feedback in person and via reports to departments on trends.
  • Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
  • Ensures appropriate system wide Infection Control Protocols are in place including regular auditing to measure effectiveness.
  • Must adhere to FHLC policies and procedures.
  • Regular and Reliable Attendance.
  • Other duties as assigned.
  • Must be able to travel to other FHLC sites.
  • Work collaboratively to create and implement organizational strategy.
  • Manage upcoming events, deadlines, and expectations.

Family Health La Clinica is proud to be an Equal Opportunity Affirmative Action employer.

  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
  • This position requires an individual who has the ability to work independently, is able to work under pressure, is analytical and has excellent problem-solving skills.
  • The individual must have the ability to respect the confidentiality of patient information while performing job duties and the ability to establish and maintain effective working relationships with patients, employees and public. 
  • Understanding and knowledge of the operations of a FQHC and PCMH standards preferred.
  • Must maintain a state of Wisconsin Driver’s License, as well as the ability to pass the requirements to complete the minimum requirements to operate a company vehicle. 
  • Bachelor’s Degree in Health-Science related program required.  BSN or Associate Degree in Nursing preferred.
  • Experience leading process improvement and quality programs. Knowledge of QA/QI program in a FQHC setting preferred. 
  • Strong ability to read and interpret data.
  • Detail oriented with excellent communication skills. 
  • Strong knowledge and ability to use Microsoft products required (Word, Excel, and Outlook).   Knowledge of improvement methods. 
  • Must have the ability to recognize problems, get to the root cause, problem solve, prioritize, experiment, implement and sustain results.
  • CPR/BLS certification required within six months of hire.

Family Health La Clinica(FHLC) requires employees to be vaccinated against COVID-19, or hold a legally recognized exemption as a condition of employment.  Where permitted by law, candidates who are offered a position will be asked about their vaccination status, which must meet minimum business requirements. All religious, medical, or other legally recognized exemptions regarding vaccination status will be considered.

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