Quality Manager

Job Description

Title: Quality Manager

Location: 1111 Leffingwell Ave. NE, Grand Rapids, MI, 49525 (Must be willing and able to travel to other OAM locations as necessary)

Schedule: Full-Time (40 Hours/Week), office hours are Monday-Friday, 8AM-5PM

Work Environment: Onsite in a clinical setting

About Us

Orthopaedic Associates of Michigan (OAM) is proud to be West Michigan's most established orthopaedic practice. Our physicians and team members provide exceptional, individualized care for patients of all ages. As the most comprehensive independent provider of musculoskeletal care in the region, we provide total care from diagnosis, to treatment, and all the way through rehabilitation.


Patients at OAM will have access to our Specialized Surgeons, Physical and Occupational Therapists, MRI and X-ray services, and orthopaedic bracing. Patients are also able to receive care from our Bone Health Clinic, OAM Now Urgent Orthopaedic Care Clinic, and Surgery Center at MidTowne - all of which are committed to optimizing their treatment outcomes.


Our teams work together to maximize and adjust treatment quickly and easily, resulting in a smoother, faster recovery for patients. From neck to toe, and from traumatic injuries to chronic conditions, patients will receive compassionate care that will allow them to embrace their full potential. Patient goals are our goals - we will restore their health so they are functioning as fully as possible in the activities they love at home, work, and in everyday life.

Position Summary

The Quality Manager leads Orthopaedic Associates of Michigan's clinical quality, patient and workplace safety, peer review, OSHA compliance, and value-based care activities. This position develops consistent processes for evaluating performance, identifying risk, investigating incidents, and monitoring corrective actions across OAM locations and service lines. The Quality Manager uses clinical, safety, claims, utilization, and patient-outcome information to identify opportunities for improvement and support regulatory readiness. This role collaborates closely with physicians, clinical and operational leaders, Human Resources, Revenue Cycle, Information Technology, and external partners to translate program and regulatory requirements into practical workflows. The position also coordinates quality, safety, and peer review committee activities and promotes a culture of accountability, transparency, and continuous improvement.

Supervision

This role has no direct reports, but will act as the subject matter expert for OAM.


Essential Responsibilities

Clinical Quality and Patient Safety Duties:

• Develops, implements, and maintains OAM's organization-wide quality management program and annual quality plan.
• Identifies appropriate clinical, operational, safety, and patient-experience measures and establishes performance targets.
• Reviews clinical outcomes, patient complaints, adverse events, near misses, utilization, and patient-reported outcomes to identify trends and improvement opportunities.
• Leads quality improvement initiatives across clinical departments, locations, and orthopaedic subspecialties.
• Develops and standardizes clinical pathways, workflows, and documentation expectations in collaboration with physicians and operational leaders.
• Coordinates investigations, root-cause reviews, corrective action plans, and follow-up related to patient safety events.
• Administers quality- and safety-related activities within the organizations reporting systems, including incident review, risk mitigation, corrective action tracking, and regulatory readiness.
• Prepares dashboards and presents actionable quality and safety findings to executive leadership, physician leadership, and applicable committees.
• Supports registry-based quality improvement and evaluates opportunities for participation in relevant orthopaedic registries and collaborative quality initiatives.
• Escalates significant or unresolved quality and patient safety concerns through established leadership channels.

OSHA and Workplace Safety Duties:

• Oversees OAM's OSHA compliance program and associated reporting requirements.
• Maintains OSHA 300 logs and other required workplace safety documentation.
• Coordinates the workplace Safety Committee, including agendas, minutes, reporting, and action-item follow-up.
• Investigates needlesticks, bloodborne pathogen exposures, and other employee safety incidents in collaboration with Human Resources and operational leadership.
• Oversees fire safety, emergency preparedness, evacuation procedures, and required drills.
• Maintains workplace safety policies and procedures in accordance with regulatory requirements and organizational needs.
• Conducts safety audits, inspections, and risk assessments across OAM locations.
• Develops and monitors corrective action plans arising from safety incidents, audits, or regulatory findings.
• Monitors completion of required OSHA and workplace safety training and communicates deficiencies to Human Resources and responsible leaders.
• Maintains readiness for OSHA inspections and other safety-related regulatory reviews.

Peer Review Duties:

• Coordinates OAM's clinical peer review program in partnership with physician leadership.
• Ensures peer review cases are identified, assigned, evaluated, documented, and closed consistently and within established timeframes.
• Prepares case materials and provides administrative support to physician reviewers and committees.
• Tracks peer review findings, recommendations, education, corrective actions, and follow-up.
• Evaluates peer review findings for recurring trends and opportunities for system-wide improvement.
• Maintains the confidentiality of peer review information and follows established processes intended to preserve applicable legal protections.
• Supports physician leadership while ensuring clinical determinations remain under physician authority.

Value-Based Care Program Oversight:

• Serves as OAM's internal operational lead for applicable value-based care, bundled payment, shared-savings, and payer quality programs.
• Develops workflows for identifying, enrolling, documenting, monitoring, and coordinating care for eligible patients.
• Coordinates communication among physicians, clinical staff, therapy providers, hospitals, ambulatory surgery centers, post-acute providers, care managers, patients, and other care partners.
• Establishes clinical escalation processes for emergency department visits, readmissions, potential complications, and deviations from expected recovery.
• Monitors patient progress, program participation, documentation, utilization, outcomes, and required reporting.
• Reviews clinical, claims, cost, utilization, registry, and patient-reported outcome data to identify opportunities to improve quality and reduce avoidable costs.
• Educates physicians and staff regarding program requirements, documentation standards, and clinical workflows.
• Prepares OAM for emerging Centers for Medicare & Medicaid Services and commercial payer programs applicable to musculoskeletal care.
• Evaluates care management, patient engagement, remote patient monitoring, virtual rehabilitation, and other tools that may support patient care.
• Supports payer, employer, and bundled-care opportunities by helping demonstrate the quality, outcomes, efficiency, and value of OAM's services.

Administrative and Leadership Duties:

• Coordinates OAM's Quality, Safety and Peer Review Committee, including meeting preparation, reports, minutes, and action-item follow-up.
• Maintains a calendar of applicable quality, safety, OSHA, payer, and regulatory requirements.
• Conducts audits of clinical workflows, safety practices, and documentation and coordinates responses to identified findings.
• Provides education to physicians, providers, managers, and staff regarding quality, patient safety, workplace safety, incident reporting, and value-based care requirements.
• Collaborates with Human Resources, Revenue Cycle, Information Technology, clinical operations, legal counsel, and external experts as appropriate.
• Partners with Human Resources while maintaining a clear division of responsibility: Human Resources retains ownership of onboarding administration, training assignments, employee records, workers' compensation coordination, OIG checks, and employee relations matters.
• Leads the safety investigation and prevention components of employee injury and exposure events while Human Resources manages workers' compensation and employment-related follow-up.
• Recommends changes to policies, workflows, education, and safety practices based on identified trends, regulatory requirements, and organizational priorities.
• Performs other related duties as assigned to support OAM's quality, safety, and strategic objectives.

Required & Preferred Qualifications

Education, Training, and Experience:

• Required:
  • Current, unrestricted Registered Nurse license.
  • Minimum of five years of relevant healthcare experience.
  • Experience in clinical quality, patient safety, regulatory compliance, care management, or healthcare operations.
  • Working knowledge of OSHA requirements and workplace safety practices.
  • Demonstrated experience evaluating clinical documentation and patient care processes.
  • Experience collaborating with physicians and multidisciplinary teams.
• Preferred:
  • Bachelor of Science in Nursing.
  • Experience in an orthopaedic, ambulatory, physician-practice, or multispecialty setting.
  • Experience coordinating peer review, quality, or safety committees.
  • Experience with OSHA reporting, employee exposure investigations, and workplace safety programs.
  • Experience with value-based care, bundled payments, payer quality programs, or care management.
  • Experience analyzing clinical, claims, utilization, cost, registry, or patient-reported outcome data.
  • Knowledge of MIPS, CMS quality programs, HIPAA, and ambulatory regulatory requirements.
  • CPHQ, CPPS, CHC, CPHRM or comparable certification, or willingness to obtain an applicable certification.

Specific Skills, Knowledge, and Abilities:

• Strong clinical judgment and the ability to distinguish clinical quality concerns from administrative or workflow issues.
• Knowledge of quality improvement methods, patient safety principles, OSHA requirements, and regulatory readiness practices.
• Knowledge of proper infection control practices and principles.
• Ability to analyze complex data and translate findings into practical recommendations and measurable improvement plans.
• Strong verbal, written, presentation, and interpersonal communication skills.
• Ability to collaborate credibly and effectively with physicians, providers, staff, executive leaders, and external partners.
• Excellent organizational, project management, prioritization, and follow-through skills.
• Ability to conduct objective investigations, manage sensitive information, and maintain confidentiality.
• Ability to lead cross-functional initiatives and influence outcomes without direct authority over all participants.
• Working knowledge of electronic health records, incident-reporting systems, Microsoft Office applications, and healthcare data-reporting tools.
• Ability to work independently, exercise sound judgment, and appropriately escalate significant concerns.

Motor, Sensory, and Physical Requirements:

• Ability to sit and/or stand for extended periods of time.
• Ability to walk throughout clinical and administrative locations while conducting audits, inspections, and investigations.
• Ability to occasionally bend, stoop, reach, and lift or carry items weighing up to 25 pounds.
• Manual dexterity required to operate computers and modern office equipment.
• Normal or correctable range of hearing and eyesight.
• Ability to travel between OAM locations and attend meetings or educational activities as required.