Manager of Clinical Risk and Quality Improvement

Fair Haven Community Health Care 

For over 54 years, FHCHC has been an innovative and vibrant community health center, catering to multiple generations with over 165,000 office visits across 21 locations. Guided by a Board of Directors, most of whom are patients themselves, we take pride in being a healthcare leader dedicated to delivering high-quality, affordable medical and dental care to everyone, regardless of their insurance status or ability to pay. Our extensive range of primary and specialty care services, along with evidence-based programs, empowers patients to make informed choices about their health. As we expand our reach to underserved areas, our commitment to prioritizing patient needs remains unwavering. FHCHC's mission is to enhance the health and social well-being of the communities we serve through equitable, high-quality, and culturally responsive patient-centered care.

Job purpose

The Manager of Clinical Risk and Quality Improvement manages the day-to-day operations of the organization’s clinical risk mitigation and quality improvement analysis. This role ensures continuous compliance with Federal Tort Claims Act (FTCA) deeming standards and HRSA Health Center Program requirements. The manager identifies clinical vulnerabilities through formal assessments and collaborates with the Data and Analytics Department to interpret dashboards and lead performance improvement projects.

Duties and responsibilities

Reporting to the Chief Corporate Compliance Officer, the Manager of Clinical Risk and Quality Improvement manages Center’s clinical risk and quality improvement programs. Typical duties include but are not limited to:

FTCA & Clinical Risk Operations

• Deeming Application Management: Leads the technical data collection and administrative assembly of the Risk Management and Credentialing and Privileging (C&P) sections of the annual FTCA deeming and redeeming applications to ensure all submissions meet HRSA/BPHC standards.
• Systemic Risk Assessments: Executes comprehensive annual clinical risk assessments across all departments to identify vulnerabilities and satisfy federal requirements.
• Incident & RCA Coordination: Facilitates investigations into clinical incidents and “near misses,” leading Root Cause Analysis (RCA) in collaboration with clinical leadership.
• Patient Grievances: Oversees the formal grievance process, ensuring systemic issues are identified and addressed to mitigate organizational liability.
• Risk Reporting: Synthesizes clinical risk data into high-level reports for the CCO, CMO, and the Board of Directors to guide strategic decision-making.
• Committee Support: Coordinate the Risk Management Committee, including agenda preparation and minute-taking.

Compliance Monitoring

• Credentialing & Privileging Compliance Monitoring: Monitors the overall compliance of the Credentialing & Privileging system, ensuring that processes for Licensed Independent Practitioners (LIPs), Other Licensed or Certified Practitioners (OLCPs), and Other Clinical Staff (OCSs) meet HRSA standards.
• Regulatory Auditing: Conducts periodic audits of credentialing files and tracking systems to ensure primary source verification and fitness for duty are documented correctly by the Credentialing Manager.
• Performance Tracking Oversight: Monitors the administrative framework for Focused Professional Practice Evaluations (FPPE) and Ongoing Professional Practice Evaluations (OPPE) to ensure timely completion.

Quality Improvement & Committee Support

• Support to CCO: Provides analyzed clinical data and evidence-based findings to the CCO to support their reporting to the QIC and the Board of Directors.
• QI Analysis: Partners with the Data and Analytics Department to review generated dashboards, identifying trends and opportunities for clinical performance improvement.
• Focused Projects: Designs and executes targeted QI projects based on FTCA, The Joint Commission Ambulatory Care and PCMH requirements, and clinical outcomes.
• Technical Guidance: Facilitates the “Plan-Do-Study-Act” (PDSA) cycle for clinical teams and provides “just-in-time” coaching on QI methodologies.
• Accreditation Readiness: Maintains clinical documentation for The Joint Commission (TJC) and NCQA PCMH status to ensure workflows meet patient safety standards.

Education, Training, & Policy Implementation

• Training Curriculum: Designs and implements the annual clinical risk and privacy training plan for all staff to satisfy mandatory FTCA requirements.
• Staff Education: Conducts educational sessions for clinical and administrative staff on risk reduction and regulatory compliance.
• Policy Integrity: Leads the drafting and periodic revision of clinical risk policies to reflect current regulatory changes and internal audit outcomes.

Qualifications

• Bachelors’ degree required; graduate degree in nursing, public health, or other relevant field is preferred; at least 5 years of professional experience also required. The selected candidate will have:
• Excellent communication (verbal, written, and presentation) skills
• Strong project management skills managing complex, multifaceted projects resulting in measurable successes and program growth
• Quality improvement, systems change, and policy development skills
• Strong analytic skills; experience mining an EHR for required data
• Demonstrated knowledge of federal and state regulations

Direct Reports

• None

American with Disabilities Requirements:

External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job specific responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case by case basis.

Fair Haven Community Health Care is an Equal Opportunity Employer. FHCHC does not discriminate on the basis of race, religion, color, sex, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need.