QI (Quality Improvement) Manager

Job Description

Job Description

The QI (Quality Improvement) Manager role provides leadership and oversight for BLEHEALTH’s Quality Improvement (QI), Performance Improvement (PI), Compliance, Risk Management, Patient Safety, and Care Management quality functions. This role works in close partnership with the RN Clinical Director and Clinical Oversight Manager to ensure clinical accuracy, documentation quality, care gap closure, and continuous improvement in member outcomes.

The QI Manager role ensures organizational readiness for audits, regulatory compliance, accreditation standards, and health plan requirements. This position supports clinical oversight by reviewing charts, validating care plans, monitoring care delivery, and ensuring documentation completeness to prevent avoidable hospitalizations through proactive intervention.

This role requires strong clinical judgment, regulatory expertise, analytical skills, and the ability to lead teams through continuous improvement processes while supporting BLEHEALTH’s mission, vision, and values.

Key Responsibilities

Quality Improvement & Performance Improvement

• Lead the development, implementation, and evaluation of BLEHEALTH’s Performance Improvement Program.

• Ensure member charts are complete, compliant, and audit ready by working directly with Lead Care Managers, Housing Navigators, and QI Coordinators.

• Oversee documentation quality—including assessments, care plans, referrals, and progress notes—by reviewing charts and ensuring accuracy, completeness, and regulatory compliance.

• Provide clinical guidance and feedback to staff regarding documentation quality, care gap closure, and regulatory requirements.

• Collaborate with staff and supervisors to correct deficiencies and ensure continuous improvement in documentation practices.

• Support QI Coordinators in chart audits, data validation, and readiness for internal and external reviews.

• Develop and maintain the QI work plan, reporting calendar, and performance measurement systems.

• Conduct data collection, aggregation, analysis, and reporting for clinical and operational metrics.

• Lead improvement cycles using PDSA, Lean, Six Sigma, or similar methodologies.

• Identify performance gaps and implement corrective action plans.

• Ensure continuous audit readiness and compliance with regulatory, accreditation, and health plan requirements.

• Oversee HEDIS and non-HEDIS data collection, tracking, trending, and reporting.

• Monitor medical record completeness, documentation quality, and audit outcomes.

• Facilitate staff training on QI tools, documentation standards, and performance initiatives.

• Promote a culture of continuous quality improvement across BLEHEALTH.

Regulatory Compliance & Accreditation

• Maintain current knowledge of CDPH, CMS, MediCal, CalAIM, and accreditation standards.

• Ensure compliance with all regulatory requirements and health plan contracts.

• Prepare and submit mandatory reports to regulatory agencies.

• Coordinate internal and external audits, including documentation requests and corrective action plans.

• Maintain BLEHEALTH’s Compliance Program, including annual evaluations and updates.

• Respond to Statements of Deficiencies, Plans of Correction, grievances, and complaints within required timelines.

• Ensure policy and procedure standards comply with local, state, and federal regulations.

• Coordinate continuous readiness for Joint Commission, DHCS, MEDI-CAL, and health plan audits.

Risk Management & Patient Safety

• In collaboration with the HR Manager, oversee BLEHEALTH’s Risk Management Program, including incident reporting, investigations, and follow up.

• Conduct Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA).

• Develop and maintain the Patient Safety Program and related policies.

• Collaborate with clinical leadership on sentinel events, near misses, and adverse events.

• Ensure timely completion of incident reports and corrective actions.

• Maintain risk management documentation, corrective action plans, and follow up activities.

Clinical Quality Oversight & Care Gap Management

• Support clinical leadership by reviewing member charts for clinical accuracy, care gaps, and adherence to care plans.

• Ensure care plans are clinically appropriate, updated, and aligned with member needs and regulatory requirements.

• Verify that care is being delivered as documented and that interventions are timely and evidence based.

• Conduct targeted chart audits to ensure completeness, accuracy, and compliance with MediCal, CalAIM, CDPH, CMS, and health plan standards.

• Identify care gaps (preventive care, chronic disease management, followup care, medication adherence, SDoH needs) and work with staff to close them.

• Review medical visit summaries, discharge instructions, and transition of care documents to ensure appropriate followup and prevent avoidable hospitalizations.

• Participate in case conferences and interdisciplinary team meetings to provide clinical insight and ensure care plans reflect current member needs.

• Use clinical data and QI metrics to identify members at risk for ED utilization or hospitalization and initiate early intervention strategies.

• Ensure timely outreach to eligible members and verify that care management activities are documented accurately and completely.

• Maintain communication with MCPs and contractual partners regarding QI activities.

• Ensure accurate data input and compliance with MCP standards.

Data, Reporting & Documentation

• Organize, compile, and interpret clinical and operational data for trending and reporting.

• Maintain electronic storage of QI reports, dashboards, and performance data.

• Prepare presentations and reports for internal leadership, committees, and external partners.

• Identify benchmarks and excellence targets to guide improvement priorities.

• Ensure accurate and timely reporting, billing, and data management.

Leadership & Collaboration

• Lead cross-functional improvement teams and committees.

• Train, mentor, and support staff to provide appropriate QI/QA services.

• Support onboarding, member grievances, and QI staff development.

• Collaborate with HR and Business Development to update marketing materials, health education content, and website information.

• Participate in interdepartmental process improvement forums and committees.

• Promote BLEHEALTH’s mission, vision, values, and service standards.

Customer Service & Professional Conduct

• Provide excellent customer service to members, staff, and partners.

• Maintain confidentiality in accordance with HIPAA and organizational policies.

• Demonstrate professionalism, accountability, and responsiveness.

• Accept constructive feedback and modify actions accordingly.

• Uphold BLEHEALTH’s customer service standards and performance expectations.

Required Qualifications

• 4+ years of recent experience in quality improvement, performance improvement, risk management, or clinical oversight in an acute care, home health, primary care, or managed care environment.

• High-level knowledge of:

o    Home Health & Home Care

o    Case Management

o    UDS & HEDIS

o    CalAIM

o    CDPH, CMS, and MediCal regulations

• Excellent written and verbal communication skills.

• Intermediate proficiency in Microsoft Office; advanced Excel skills required.

• Ability to understand, translate, and communicate written and auditory information accurately.

• Demonstrated ability to supervise and direct professional and administrative personnel.

• Knowledge of business management and governmental regulations.

• Participation in Quality Assurance/Performance Improvement programs.

• Valid driver’s license and insured, reliable transportation.

Preferred

• Master’s degree in public health, Healthcare Administration, Nursing Leadership, or related field; OR Bachelor’s degree with 2–3 years of additional relevant experience.

• Three years of management experience within the last five years in home health or related healthcare settings.

• Experience leading QI teams in home health, managed care, or community health settings.

• Knowledge of Lean, Six Sigma, or other improvement methodologies.

• Experience with accreditation readiness (Joint Commission, NCQA, CHAP, etc.).

• Bilingual (English/Spanish) preferred.

Physical & Environmental Requirements

• Ability to lift up to 35 pounds.

• Ability to stand, walk, and navigate clinical and office environments.

• Ability to travel to BLEHEALTH sites, partner locations, and community settings.

• Ability to work in a fast-paced environment with competing priorities.