Quality and Compliance Manager

Job Description

The Quality and Compliance Manager in healthcare leads organizational efforts to ensure high standards of patient care while adhering to federal, state, and accreditation regulations. The position is accountable for driving sustained improvement through workflow redesign, data analysis, service utilization assessment and cross-functional collaboration

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The Quality and Compliance Manager is responsible for leading the organization’s quality improvement, performance management, patient safety, compliance, and population health initiatives across the organization. This role develops and implements strategies that improve patient experience, operational efficiency, innovation, and practice transformation performance that enhances patients’ clinical outcomes, creates a culture of safety, and improves staff experience. The Quality and Compliance Manager utilizes health information technology, reporting tools, and data systems to support the activities of the clinical care team, resulting in improved performance of quality indicators and care-based incentive measures, including but not limited to HEDIS, UDS, GPRA and others that support the improved patient care.  

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The Quality and Compliance Manager is also responsible for developing, implementing, and overseeing the organization’s compliance program to ensure adherence to all applicable federal, state, and local laws, regulations, and standards governing Federally Qualified Health Centers (FQHCs). This position supports organizational integrity by promoting ethical practices, mitigating risk, monitoring regulatory compliance, and fostering a culture of accountability throughout the health center.

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Essential Duties and Responsibilities:

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Primary Functions:

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Quality Improvement & Performance Management

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1.    Leads organization-wide quality improvement (QI) initiatives using data-driven methodologies and continuous improvement principles.

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2.    Develops, implements, and monitors the annual Quality Management Plan and Quality Improvement Work Plan and addresses areas of improvement opportunities.

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3.    Oversees clinical quality metrics including UDS measures, HEDIS, GPRA, and other quality performance indicators.

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4.    Coordinates efforts of patient engagement in preventive health measures, including health promotion and disease prevention initiatives.

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5.    Facilitates root cause analyses, corrective action plans, and performance improvement projects.

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6.    Works with the clinical team and clinical directors to conduct Quality Assessments and Peer Review activities.

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7.    Coordinates Quality Committee meetings and maintains all records of the minutes and related activities.

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8.    Conducts quarterly evaluation of the Quality Management program that is subsequently presented to the Board of Directors.

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9.    Collaborates with the clinical directors in the development and implementation of clinical guidelines.

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10. Develops and maintains policies and procedures related to quality improvement and patient safety.

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11. Ensures quality improvement activities are well-documented and audit ready.

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12. Ensures quality improvement efforts align with regulatory requirements

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Compliance Program Administration

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1.    Assist in the development, implementation, and maintenance of the organization’s corporate compliance program. Develops a comprehensive Corporate Compliance Program Plan that is ultimately approved by the Board of Directors.

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2.    Monitor compliance with federal and state healthcare regulations, including HRSA, HIPAA, OSHA, CMS, Medicare, Medicaid, OIG, FTCA. And 340B guidance.

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3.    Maintains adherence to regulatory requirements and accreditation standards including but not limited to CARF, PCHM, and AAAHC. 

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4.    Maintain and update compliance policies, procedures, and standards of conduct.

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5.    Coordinate annual compliance assessments and mitigation strategies.

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6.    Conducts staff training and supports culture building.

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7.    Conducts security risk assessments in collaboration with Risk Management.

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8.    Conducts routine internal audits and monitoring activities related to billing, coding, documentation, privacy, and operational compliance.

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9.    Investigate compliance concerns, incidents, and potential violations, and assist in corrective action planning.

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10. Monitor implementation and effectiveness of corrective actions.

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11. Support preparation for HRSA Operational Site Visits (OSVs), audits, and regulatory reviews.

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12. Supports HIPAA privacy and security compliance activities.

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13. Monitors adherence to patient confidentiality and protected health information (PHI) requirements.

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14. Assist with breach investigations, documentation, and reporting as required by law.

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Data Analytics & Reporting

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1.    Analyzes quality, utilization, and population health data to identify trends and opportunities for improvement.

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2.    Works closely with the Data Analytics and Information Technology teams in the development of reports and visualizations or dashboards of data that is applicable, accurate and useful in measuring quality indicators.

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3.    Oversees submission and validation of UDS, HEDIS and GPRA reporting and other regulatory quality reports.

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4.    Collaborates with IT and informatics teams to optimize EHR workflows and clinical reporting capabilities.

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5.    Collaborate with IT and Security teams on compliance-related safeguards and training.

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Workflow Analysis & Process Improvement

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1.    Leads analysis of clinical and operational workflows impacting quality outcomes.

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2.    Identifies breakdowns in processes related to screening, follow-up, documentation, and patient engagement.

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3.    Designs and implements workflow changes to improve performance and close care gaps.

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4.    Ensures workflow changes are standardized, documented, and scalable across sites or departments.

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5.    Monitors post-implementation results to ensure improvements are sustained and measurable.

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Interdepartmental Collaboration

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1.    Collaborates with Human Resources in the development of a quality staff training program.

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2.    Partners with clinical leadership, care management, PSR, referrals, IT, and grants teams to drive quality improvement.

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3.    Supports the development of quality indicators for health promotion and disease prevention initiatives.

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4.    Integrates grant funded programing in the quality improvement objectives.

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5.    Works with PSRs, care coordinators, CHWs, and other teams to ensure outreach activities align with quality goals.

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6.    Brings data-driven recommendations to leadership to address underperforming measures.

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7.    Ensures accountability across teams contributing to quality outcomes.

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8.    Supports change management efforts to ensure adoption of new workflows.

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Qualifications:

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Minimum Qualifications:

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1.    Bachelor's degree from an accredited college or university in Nursing, Quality, Social Work, or other health related field preferred.

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2.    Minimum 3–5 years’ experience in healthcare quality improvement, population health, or performance management.

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3.    Some knowledge of Clinical Compliance, Best Practices, Medical Record Review, Legal Aspects of Documentation, or medical coding and billing preferred.

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Preferred:

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1.    Experience in Compliance, Risk Management, Quality Management, Documentation Standards, Billing, and Coding knowledge.

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2.    Experience serving a multinational, multicultural population.

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3.    FQHC background.

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1. Familiarity with Community Health Clinics and/or Indian Health Clinics.
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• 5.    ECW EHR.
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