Quality Improvement Manager

Quality Improvement Manager

The Quality Improvement Manager is responsible for planning, implementing, coordinating, and evaluating the organization's Quality Improvement (QI), Performance Management, Accreditation, and Compliance programs. This position provides leadership in fostering a culture of continuous quality improvement and operational excellence throughout the organization. The Quality Improvement Manager works collaboratively with executive leadership, program managers, and staff to ensure services meet regulatory, contractual, and accreditation requirements while achieving organizational goals and objectives. This position leads quality improvement initiatives, analyzes organizational performance data, monitors corrective action plans, prepares accreditation activities, and develops comprehensive reports and dashboards to support data-driven decision-making. The Quality Improvement Manager is responsible for preparing and presenting monthly quality, compliance, performance, and outcome reports to Executive Leadership and the Governing Body and serves as a key resource for quality enhancement, accreditation readiness, and organizational effectiveness.

Essential Duties and Responsibilities:

Quality Improvement and Performance Management: Develop, implement, maintain, and evaluate the organization's Quality Improvement Program. Coordinate agency-wide quality enhancement and performance improvement initiatives. Establish, monitor, and evaluate key performance indicators (KPIs) and organizational outcome measures. Facilitate quality improvement committees, workgroups, and performance review meetings. Identify opportunities for improvement and develop strategies to enhance service delivery and operational effectiveness. Monitor and evaluate the effectiveness of quality improvement projects and initiatives. Develop, track, and report quality improvement goals aligned with the organization's strategic plan. Lead root cause analyses and performance improvement activities when service deficiencies or compliance concerns are identified. Ensure continuous monitoring of organizational performance metrics and benchmarks. Promote a culture of continuous quality improvement throughout the organization.

Data Analysis, Reporting, and Outcomes Management: Collect, analyze, interpret, and report organizational performance and outcome data. Develop and maintain organizational quality dashboards and scorecards. Prepare and present monthly quality, compliance, performance, and outcome reports for Executive Leadership and the Governing Body. Develop reports that identify trends, opportunities for improvement, corrective actions, and organizational successes. Monitor customer satisfaction, stakeholder feedback, and service outcomes. Analyze operational, clinical, administrative, and financial performance measures. Monitor progress toward strategic goals, quality objectives, and accreditation standards. Ensure the integrity, accuracy, and reliability of quality and performance data. Provide recommendations based on data analysis to support organizational decision-making. Prepare quarterly and annual quality management reports and program evaluations.

Accreditation and Regulatory Compliance: Coordinate accreditation preparation, readiness, and survey activities. Monitor compliance with CARF, state, federal, licensing, and contractual requirements. Conduct internal audits, assessments, and compliance reviews. Maintain accreditation documentation and evidence files. Assist departments in implementing corrective action plans following audits, surveys, or reviews. Monitor corrective action completion and effectiveness. Track changes in regulatory, accreditation, and contractual requirements and communicate updates to leadership. Provide technical assistance to departments regarding compliance expectations and standards. Participate in accreditation surveys, audits, and regulatory site visits.

Policy and Procedure Management: Coordinate the annual review and revision process for organizational policies and procedures. Assist leadership in developing new policies consistent with regulatory and accreditation requirements. Ensure policies remain current, effective, and compliant with applicable standards. Maintain records related to policy reviews, approvals, and revisions. Provide guidance to staff and management concerning policy implementation and interpretation.

Training and Staff Development: Develop and provide training related to quality improvement, compliance, accreditation, performance measurement, and organizational standards. Educate staff on quality improvement methodologies and best practices. Assist departments in understanding performance expectations and outcome measures. Support management in implementing quality improvement tools and processes. Provide coaching and technical assistance regarding quality initiatives.

Collaboration and Leadership Support: Collaborate with leadership and program management to establish quality goals and performance expectations. Serve as a resource to management regarding quality improvement, accreditation, and compliance matters. Participate in strategic planning and organizational development activities. Build effective working relationships across departments and programs. Represent the organization in quality, accreditation, and compliance-related meetings as assigned. Perform other duties as assigned by the Chief Administrative Officer or designee.

Minimum Qualifications:

Education:

• Bachelor's degree in Healthcare Administration, Public Health, Business Administration, Human Services, Social Work, Nursing, Organizational Leadership, or a related field required.
• Master's degree preferred.

Experience:

• Minimum of three (3) years of progressively responsible experience in quality improvement, compliance, accreditation, healthcare administration, behavioral health, developmental disabilities services, or a related field.
• Experience with performance measurement, data analysis, reporting, and quality management systems required.
• Experience with accreditation processes and standards preferred.
• Supervisory or project leadership experience preferred.

Preferred Qualifications:

• Master's degree in a related field.
• Certified Professional in Healthcare Quality (CPHQ) or similar certification.
• Experience with CARF accreditation standards and survey preparation.
• Experience developing organizational dashboards and performance scorecards.
• Experience in community behavioral health, public health, or human services organization
• Advanced proficiency in Microsoft 365 applications, including SharePoint Online, Power Automate, Power BI, Teams, Forms, Planner, Excel, and related collaboration and reporting tools. Experience designing automated workflows, managing document repositories, developing quality dashboards, and utilizing data analytics to support quality improvement, compliance, accreditation, and operational excellence initiatives is highly desirable.

Middle Flint Health & Wellness services the following 11 counties: Webster, Marion, Sumter, Schley, Taylor, Crisp, Dooly, Macon, Houston, Peach and Crawford.

Middle Flint Health & Wellness is a Drug Free Workplace. Current Middle Flint applications should be filled out carefully and completely. Describe background in full and make certain application is signed. Incomplete applications or applications with insufficient information can result in an applicant not being considered for the vacancy. Please KEEP a copy of your application. All applications must be received (not postmarked) by the above specified deadline. Finger-printing and/or Drug Screening may be required, if appointed. Any male applicant between 18 and 26 years of age must present proof of having registered with the Selective Service as required by federal and state law, or of being exempt from such registration.

An Equal Opportunity Employer

Middle Flint Health & Wellness does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its programs and activities. An applicant who has a disability which requires special accommodations should contact this office.

Entry Salary may be adjusted depending upon the selected candidate's qualifications and agency budget considerations.

Benefits Offered Include:

Leave – Paid Time Off

Retirement – Retirement Plan

Insurance – Dental, Disability, Medical, Health Savings, Life, Vision; Legal; Accident

Miscellaneous – Flexible Spending Account; Paid Orientation/Training; Free Parking

Professional Development – Clinical Supervision for Licensure track