Director of Quality and Risk Management

About Community Health Partnership of Illinois Community Health Partnership of Illinois (CHP) is a nonprofit healthcare organization dedicated to providing accessible, high-quality primary medical, dental, and behavioral healthcare services to underserved communities throughout Illinois. With over 55 years of service, CHP proudly serves more than 10,000 patients across six counties in central and northern Illinois. Our mission is to improve the health and well-being of the communities we serve through compassionate, patient-centered care. Position Summary Community Health Partnership of Illinois is seeking an experienced and dedicated Director of Quality and Risk Management to lead and oversee the organization's quality improvement, patient safety, regulatory compliance, and risk management programs. This leadership position plays a critical role in ensuring compliance with Health Resources and Services Administration (HRSA) Health Center Program requirements, The Joint Commission accreditation standards, and applicable federal and state healthcare regulations. The Director will collaborate closely with clinical leadership, Human Resources, and administrative teams to promote patient safety, minimize organizational risk, strengthen clinical performance, and foster a culture of continuous quality improvement across CHP locations. Key Responsibilities Quality Improvement & Performance Management Develop, implement, and oversee the organization's Quality Improvement and Quality Assurance (QI/QA) programs. Lead staff and Board Quality Improvement/Quality Assurance Committee meetings. Establish and monitor quality improvement initiatives using data-driven methodologies, including Plan-Do-Study-Act (PDSA) cycles and Lean Six Sigma principles. Track and improve Uniform Data System (UDS) clinical performance measures, including hypertension control, diabetes management, colorectal cancer screening, and other quality indicators. Supervise the Data Integrity Manager and oversee organizational data analysis activities. Identify opportunities to enhance patient outcomes, operational efficiency, and clinical performance. Risk Management & Patient Safety Develop, implement, and oversee the organization's Risk Management Program. Manage incident reporting systems, monitor near-miss events, and coordinate proactive risk assessments, including Failure Mode and Effects Analysis (FMEA). Oversee the annual Federal Tort Claims Act (FTCA) deeming application process. Ensure completion of required staff risk management training, including infection control, HIPAA, and other applicable clinical safety topics. Develop and maintain organizational emergency preparedness and Continuity of Operations (COOP) plans. Promote a proactive culture of patient safety, accountability, and risk reduction. Regulatory Compliance & Accreditation Ensure organizational compliance with the HRSA Health Center Program Compliance Manual and applicable regulatory requirements. Serve as a primary subject matter expert for The Joint Commission accreditation, working collaboratively with the Director of Nursing and clinical leadership. Coordinate accreditation readiness activities, including mock surveys, tracer activities, compliance assessments, and supporting documentation. Oversee Patient-Centered Medical Home (PCMH) certification activities and ambulatory care accreditation requirements. Prepare for and support HRSA Operational Site Visits (OSVs), FTCA deeming reviews, and other regulatory evaluations. Monitor compliance with applicable federal and state healthcare regulations and licensing requirements. Leadership & Organizational Collaboration Collaborate with Human Resources and clinical leadership to support provider credentialing and peer review processes. Provide guidance to clinical and administrative teams regarding quality improvement, risk management, and regulatory compliance. Develop and maintain organizational policies, procedures, reports, and documentation related to quality and risk management. Promote collaboration, professional accountability, and continuous improvement across all CHP locations. Perform additional duties as assigned by organizational leadership. Required Qualifications Certified Professional in Healthcare Quality (CPHQ) certification. Certified Professional in Healthcare Risk Management (CPHRM) certification. Current Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) certifications. Strong leadership, communication, organizational, and problem-solving skills. Knowledge of The Joint Commission accreditation standards and Patient-Centered Medical Home (PCMH) certification requirements. Understanding of healthcare regulations, clinical practices, medical terminology, and patient safety principles. Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook. Ability to lead quality and risk management initiatives while maintaining a safe, compliant, and professional healthcare environment. Preferred Qualifications Active Registered Nurse (RN) license. In-depth knowledge of HRSA Health Center Program requirements, FTCA guidelines, and UDS reporting. Advanced knowledge of The Joint Commission National Patient Safety Goals (NPSGs) and ambulatory care accreditation standards. Experience with Electronic Health Records (EHR) and healthcare analytics platforms, such as Azara DRVS, i2i, or similar systems. Infection Preventionist certification. Experience working in ambulatory care, Federally Qualified Health Centers (FQHCs), or similar healthcare settings. Experience managing quality improvement programs, regulatory compliance initiatives, and organizational risk management activities. Benefits CHP offers a comprehensive benefits package, including: Medical, Dental, and Vision Insurance Health Savings Account (HSA) and Health Management Tools Paid Time Off (PTO) and Company-Paid Holidays 403(b) Retirement Plan Life and Accidental Death & Dismemberment (AD&D) Insurance Short-Term Disability Insurance Accident Insurance Employee Recognition and Rewards Programs Join Our Team! Are you an experienced healthcare quality and risk management professional passionate about improving patient safety, strengthening organizational compliance, and driving meaningful healthcare improvements? At Community Health Partnership of Illinois, you'll have the opportunity to lead impactful quality and risk management initiatives while supporting our mission of providing accessible, compassionate healthcare to communities throughout Illinois. Equal Opportunity Employer Community Health Partnership of Illinois is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, national origin, age, disability, genetic information, or any other status protected by applicable law. #J-18808-Ljbffr Berliner Gasthausmission e. V.