Ambulatory Quality Program Manager

General Description: Coordinates and participates in quality monitoring and improvement activities to support a culture of quality, evidence-based practice, optimal patient outcomes, patient safety, and compliance with The Joint Commission (TJC) standards to include conducting quality reviews of medical and clinic performance on patient outcomes and quality indicators. Works with interdisciplinary performance improvement teams to achieve excellent patient outcomes and industry leading success on publicly reported quality indicators. Prepares reports and presentations to educate and communicate information and results related to infection prevention, quality outcome measures, publicly reported quality data, and regulatory requirements. Provides technical and clinical support to assist clinic and medical staff in achieving continuous readiness on TJC and regulatory standards.

Essential Responsibilities:

• Assist clinics and departments with data analysis and development of quality improvement processes.
• Capture and report quality data as needed.
• Identify and implement infection prevention and control strategies.
• Participate in the formulation and revision of policies and procedures addressing infection control.
• Collaborate with Employee Health Department to prevent the transmission of infections and to manage exposures.
• Serve as a resource for quality and accreditation information for providers and staff.
• Collect, investigate, and trend unexpected outcomes, patient safety and patient satisfaction data.
• Participate in policy development and review as needed.
• Participate on committees as assigned.
• Ensure compliance with external regulatory and certifying agencies as needed.

General Responsibilities:

• Performs other duties as assigned.

Minimum Requirements:

Education:Bachelor's degree in a Healthcare related field.

Experience:3 or more years of experience in healthcare, quality, or risk management

Equivalent/ Substitution:May substitute an Associate's Degree in lieu of the Bachelor's degree and 5 to 7 years of healthcare, quality, or risk management experience.

Licensure/Certifications/Registrations Required:None required

Knowledge, Skills & Abilities:

• Knowledge of the healthcare quality field and accrediting agencies such as JACHO, NCQA, AAAHC.
• Knowledge of how healthcare quality is evaluated, improved, and regulated within the health system.
• Knowledge of quality and safety and patient satisfaction metrics and other health metrics.
• Skill in planning and administering performance improvement activities and using performance improvement methodolog
• Ability to understand quality, safety metrics, and value based initiatives.
• Ability to make decisions, resolve conflict, set priorities, be flexible and adapt to different situations.
• Ability to work independently and in a team environment.
• Ability to understand and apply protocols, policies, and procedures.
• Ability to work under stressful situations and complete projects in a timely manner.
• Excellent written and verbal communication skills.
• Demonstrated proficiency with MS Office Suite.

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