Clinical Quality Manager (New Position)

Job Description

Job Description

Clinical Quality Manager

Clinic

Damien Center Values

Dignity-Collaboration-Accountability-Access-Quality-Innovation

Founded in 1987, Damien Center is Indiana’s oldest and largest AIDS service organization (ASO) and serves more than 8,000 individuals living with or at risk for HIV through a comprehensive, innovative approach to care and prevention. Our purpose is to be a trusted partner in providing services, education and advocacy for all people living with or at risk for HIV and any person seeking a safe and welcoming home for care. Our services include care coordination, clinical and pharmacy services, mental health, housing, and nutrition. 

Position Summary:  

The Clinical Quality Manager leads the planning, implementation, and evaluation of quality improvement (QI) and patient safety initiatives across the health center. This role ensures compliance with HIV quality measures, HRSA requirements, UDS measures, NCQA/PCMH standards, and other regulatory expectations while supporting clinical teams in delivering high quality, equitable, patient centered care. The Clinical Quality Manager collaborates closely with medical, dental, behavioral health, nursing, and operational leaders in partnership with the quality and compliance department to drive performance improvement and optimize clinical outcomes for underserved populations.

Duties and Responsibilities:

This job description describes the general nature and level of work performed by employees assigned to this position. It should not be construed as an exhaustive list of all required duties, responsibilities, and skills. 

Quality Improvement & Performance Management

• Lead the development, execution, and monitoring of the organization’s Clinical Quality Improvement Plan (QIP), ensuring alignment with Standards of Practice and Standards of Care as well as Ryan White quality standards, Community Health Center expectations, and Pharmacy Performance Improvement program.
• Facilitate clinical Quality Improvement (QI) projects using evidence-based methodologies, communicating the status and outcomes of QI projects as needed to maintain compliance with regulatory bodies and government agencies.
• Develop KPIs for clinical quality dashboards and present findings to leadership, clinical teams, and the Quality Committee of the Board of Directors on an ongoing basis.
• Identify gaps in performance and quality of care to collaborate with clinical leaders in development and implementation of corrective action plans.

Regulatory & Accreditation Compliance

• Maintain Clinical Laboratory Improvement Amendments (CLIA) certification.
• Ensure ongoing compliance with Ryan White HIV and HRSA Health Center Program for quality of care requirements. 
• Lead the clinical quality preparation for HRSA Operational Site Visits (OSVs), clinically related accreditations, and external audits.
• Monitor and regularly report adherence to federal, state, and payer quality standards.
• Lead and monitor the chart reviews for compliance, continuously tracking and evaluating documentation quality, coding accuracy, and adherence to clinical standards.

Clinical Risk Management & Patient Safety

• Serve as the subject matter expert for clinically related incident reports, grievances, adverse event review, and risk assessments while also ensuring investigation and response within the required timeline.
• Provide oversight and monitoring of all clinically related incident reports, communicating with associated parties and escalating/closing, as needed.
• Conduct root cause analyses and develop system level improvements to reduce risk.
• Actively participate in various committees to ensure compliance with credentialing, privileging, risk management, and ethics for all clinical departments.
• Manages the peer review and self-review processes for clinical staff, ensuring timely completion and confidentiality.
• Develop, implement, and oversee infection prevention and control (IPC) practices across clinical and non-clinical areas.
• Monitor compliance with infection control regulations and standards (CDC, OSHA, state/local health regulations).
• Coordinate and monitor all required activities outlined in Collaborative Practice Agreements (CPAs), serving as primary point of contact and oversight for physician compliance with CPAs.

Data Analytics & Reporting

• Track, analyze, and report performance on clinical quality measures and KPIs, including all Uniform Data System (UDS) and HEDIS measures in compliance with HRSA Health Center Program, accreditation standards, and regulatory requirements. 
• Partner with IT/Health Informatics and Quality & Compliance teams to optimize Electronic Health Record (EHR) workflows, templates, and reporting tools ensuring alignment with accreditation standards and regulatory requirements.
• Ensure ongoing accuracy in data collection and validate data accuracy to support timely submission of UDS, HEDIS, and other required reporting. Provide guidance and oversight for clinically related data collection and reporting, in compliance with data governance policies and procedures.

Staff Training & Clinical Support

• Provide coaching and education to providers, nurses, MAs, and care teams on quality measures and best practices.
• Support care coordination, population health initiatives, and chronic disease management programs.
• Collaborate with care teams to improve workflows related to screenings, immunizations, and chronic care.
• Train and support providers, nurses, and other clinical support staff in proper EHR documentation as required for accrediting bodies as well as local, state, and federal agencies to enable accurate reporting of all quality measures.
• Develop and maintain all standing orders and protocols to support efficient functionality of RNs, MAs, and other clinical support staff.

Cross Functional Collaboration

• Work with cross functional teams across the agency to improve patient engagement and outcomes for supportive services outside the clinic.
• Partner with the quality and compliance team on policy development and regulatory updates.
• Participate in grant writing, reporting, and program evaluation as needed.

All other duties as assigned.

Education and/or Experience:

Bachelor's degree in nursing, public health, healthcare administration, or related field required. Master's degree in public health, Nursing, or Healthcare Administration preferred. Registered Nurse (RN) or other medical licensure is required. 3–5 years of experience in clinical quality, population health, or healthcare performance improvement is required, with experience in direct patient care strongly preferred. Certification in Infection Prevention and Control (CIC) or Certified Professional in Healthcare Risk Management (CPHRM) is required within one year of employment. 

Proficiency with EHR systems required. Experience working with data analytics tools, including Power BI (or similar) preferred. Experience working in a Ryan White clinic, FQHC, or similar clinical safety net environment required. Strong knowledge of HIV health outcomes, HRSA requirements, and quality improvement & assurance frameworks.

*Work or lived experience may substitute for education requirements on a case-by-case basis. 

Knowledge, Skills, and Abilities:

Possess superior organizational and administrative skills. Excellent interpersonal and communication abilities. Excellent computer skills in a Microsoft Windows environment. Ability to work independently and achieve high standards of productivity, achieving deadlines and with superior product results. Strong calendaring, organizational, and document management skills required. Proactive approach to solving problems and communicating to leadership. Knowledge of office management systems, procedures, and office equipment required. Excellent time management skills and ability to prioritize work. 

Qualifications:

To perform this job successfully, an individual must be able to perform each essential job function satisfactorily. The requirements listed are representative of the basic knowledge, skills, and/or abilities required.  Reasonable accommodations may be made for individuals with disabilities to perform the essential functions.  The individual in this role must display the highest level of integrity and confidentiality. The individual should have effective communication skills, attention to detail and organization, and flexibility and adaptability. The individual will also maintain knowledge of trends in their area of responsibility.

Physical Demands:

The physical demands described here are general representations of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made for individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to sit, reach with hands and arms, talk, and hear. The employee frequently is required to use hands to touch and handle objects. The employee frequently stands or walks.
• The employee must occasionally lift and/or move up to 10 pounds.  Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made for individuals with disabilities to perform the essential functions. Remote work is on a case-by-case basis and must be approved by the supervisor. 

• Office setting, with sustained use of a computer.
• The noise level in the work environment is minimal to moderate.
• Individuals should maintain personal and professional competency and work to create an environment of courtesy, respect, inclusion, and positivity in all interactions both internal and external to the organization.

FLSA Status: Salaried, Full-time, Exempt               

Leader: Medical Director

Salary: $97,747 annually

Benefits:  

• 150 hours of PTO in the first year followed by 195 hours per year moving forward.
• 12 paid holidays
• Medical coverage options include a PPO plan or a HDHP. 
• Dental & Vision plans
• Health Saving Account or Flexible Spending Account
• Dependent Care Flexible Spending Account
• Employee Assistance Program
• 403b Retirement Account with 5% matching and 100% vesting after 90 days
• Life Insurance @ 2 times the annual salary
• Voluntary Life Insurance Plan including spouse and child coverage options
• Short- & Long-Term Disability Plans
• Premium Subscription to the CALM APP which assists with anxiety, stress & other mental health challenges
• Professional Development Opportunities
• Tuition Assistance
• Annual performance review that includes an annual performance-based salary increase

Protecting our team members, clients, volunteers, and community partners is an integral part of how we ensure our continued work with the clients we serve.  As a condition of employment, Damien Center requires team members to be vaccinated against influenza and receive a tuberculosis skin test (or chest x-ray) annually, barring an approved religious or medical exemption.    

Damien Center is an Equal Opportunity Employer

Damien Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, family status, ethnicity, national origin, age, disability, marital status, amnesty, status as a covered veteran, other legally protected status, or genetic (including family medical history) information.

Damien Center complies with applicable federal laws and with all state and local laws governing non-discrimination in employment in every location in which Damien Center has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

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This position description does not constitute a contract of employment or guarantee of any terms or conditions of employment.  Damien Center employees are employed on an at-will basis. Nothing in this position description restricts Damien Center’s right to assign or reassign duties and responsibilities to this position at any time.