Quality Improvement / Quality Assurance / Compliance Registered Nurse (QI/QA RN)

Quality Improvement / Quality Assurance / Compliance Registered Nurse (QI/QA/Compliance RN)The Quality Improvement / Quality Assurance / Compliance Registered Nurse (QI/QA/Compliance RN) is responsible for leading and supporting the health center's quality improvement, patient safety, risk management, and regulatory compliance programs. This position ensures compliance with HRSA Health Center Program Requirements, Federal Tort Claims Act (FTCA) standards, Uniform Data System (UDS) reporting requirements, and applicable Federal, State of Alaska regulations.The QI/QA/Compliance RN works collaboratively with clinical leadership, providers, nursing staff, and administrative teams to promote continuous performance improvement, patient safety, and high-quality, culturally responsive care in Alaska's rural, frontier, and remote healthcare environments.Essential Duties and ResponsibilitiesQuality Improvement (QI)Lead and coordinate the organization-wide Quality Improvement (QI) ProgramFacilitate Plan?Do?Study?Act (PDSA) cycles and performance improvement initiativesMonitor, analyze, and trend Clinical Quality Measures (CQMs), including UDS clinical measuresIdentify gaps in care and work with clinical teams to implement and sustain improvement strategiesSupport value?based care, patient?centered medical home (PCMH), and care integration initiativesIncorporate health equity principles into quality improvement activitiesQuality Assurance (QA)Conduct routine and targeted clinical chart audits to assess quality of care and documentationMonitor compliance with evidence?based guidelines, clinical protocols, and standing ordersParticipate in peer review and clinical case review activitiesIdentify quality concerns and ensure corrective actions are implemented and monitoredTrack trends related to clinical outcomes and quality indicatorsCompliance & Regulatory OversightEnsure ongoing compliance with: HRSA Health Center Program Requirements, including the HRSA Operational Site Visit (OSV); Federal Tort Claims Act (FTCA); CMS and Medicaid requirements; Alaska Board of Nursing and state regulations; HIPAA, OSHA, and CLIA (as applicable)Maintain readiness for audits, surveys, and regulatory reviews, including the HRSA Operational Site Visit (OSV)Assist with policy development, review, and revision to ensure regulatory alignmentMaintain compliance documentation and tracking toolsFTCA Risk Management & ReportingCoordinate the health center's FTCA Risk Management and Claims Prevention ProgramSupport the annual FTCA Deeming ApplicationTrack, review, and trend: incident reports; patient complaints and grievances; adverse events and near missesConduct or support root cause analyses (RCAs) and corrective action plansCoordinate follow?up actions and monitor risk mitigation strategiesMaintain required FTCA documentation and reporting recordsCollaborate with leadership and legal counsel as appropriateUniform Data System (UDS) ReportingSupport and coordinate UDS reporting and data validationValidate clinical quality measure accuracy through chart audits and data reviewCollaborate with providers, nursing, IT, billing, and data teams to ensure data integrityAnalyze UDS data to identify trends, gaps, and opportunities for improvementUse UDS results to inform quality improvement initiativesSupport timely submission of UDS data in accordance with HRSA requirementsHRSA Operational Site Visit (OSV) Compliance & ReportingEnsure continuous compliance with HRSA Health Center Program RequirementsCoordinate preparation for HRSA Operational Site Visits (OSVs), including: evidence collection and organization; policy and procedure review; staff education and readinessConduct or participate in mock site visits as neededTrack OSV findings and coordinate Corrective Action Plans (CAPs)Support post?OSV reporting and ongoing HRSA communicationsPromote continuous compliance rather than event?based preparationInfection Prevention & Patient SafetyCoordinate and support the Infection Prevention and Control ProgramMonitor compliance with CDC, HRSA, OSHA, and Alaska public health guidanceConduct infection control audits and staff educationSupport outbreak response and exposure investigationPromote a culture of patient safety and quality improvementEducation, Training & Staff SupportProvide education and training on: quality improvement methods; documentation standards; compliance and risk management requirements; infection prevention and patient safetySupport onboarding and annual competency requirementsServe as a quality and compliance resource for clinical and administrative staffData, Reporting & Committee SupportPrepare quality, compliance, and risk management reports for: leadership; quality committee; board of directors (as required)Participate in quality, compliance, and risk management committeesMaintain accurate documentation and reporting recordsAlaska?Specific ResponsibilitiesDemonstrate understanding of rural, frontier, and remote healthcare deliverySupport telehealth and remote care models used in AlaskaWork effectively with diverse populations, including Alaska Native/American Indian communitiesAdapt quality and compliance programs to limited resources, weather?related access challenges, and workforce variabilityMay require occasional travel to clinic sites, including travel by small aircraft or other rural transportationQualificationsRequiredCurrent, unrestricted Registered Nurse (RN) license in the State of AlaskaAssociate's or Bachelor's degree in Nursing (BSN preferred)Minimum 3–5 years of nursing experience, preferably in: primary care or ambulatory care; community health or public health; rural or frontier healthcareKnowledge of healthcare quality improvement, regulatory compliance, and patient safetyStrong analytical, organizational, and communication skillsProficiency with electronic health record (EHR) systemsPreferredQI/QA 2-3 years Direct ExperienceExperience in a FQHC, tribal health organization, or safety?net settingExperience with: HRSA UDS reporting; HRSA OSVs; FTCA risk managementBachelor's or Master's degree in Nursing, Public Health, or Healthcare AdministrationQuality or patient safety certification (e.g., CPHQ, CPPS)Core CompetenciesQuality improvement methodologyRegulatory compliance and audit readinessRisk management and patient safetyCultural humility and trauma?informed careCollaboration and communicationAttention to detail and accountabilityAdaptability in rural and remote environmentsPhysical & Work EnvironmentCombination of office?based and clinical area responsibilitiesAbility to sit, stand, and walk for extended periodsAbility to lift up to 25 poundsMay require travel between clinic or outreach sitesReporting RelationshipReports to: Executive Director, CEOWorks closely with: Medical Director, Nursing Leadership, Compliance Officer, Executive Team, and IT/Data teamsMission AlignmentThis position supports the health center's mission to provide high?quality, patient?centered, and culturally respectful care to Alaska's communities while ensuring regulatory compliance, patient safety, and continuous quality improvement.