Clinical Quality & Performance Improvement Manager

CLINICAL QUALITY & PERFORMANCE IMPROVEMENT MANAGER

Department:Quality

Reports To: Chief Medical Officer and Chief Quality Officer

Functional Area: Clinical Quality & Performance Improvement

Supervisory Responsibility: Clinical Quality Improvement Specialist

Primary Governance Alignment: Care Management Committee; QIC

Position Summary

The Clinical Quality & Performance Improvement Manager serves as Banyan's working lead for clinical quality measurement, performance improvement, population health quality, and structured improvement of clinical outcomes across applicable services.

The Manager is responsible for translating performance data into actionable improvement work. This includes identifying performance gaps, determining where focused intervention is required, designing and leading quality improvement initiatives, engaging clinical and operational leaders, monitoring intervention effectiveness, and escalating persistent performance barriers to the Chief Medical Officer and Chief Quality Officer.

This is a hands-on management position. The Manager is expected to directly lead significant clinical quality initiatives and performance reviews rather than functioning solely as a supervisor. Clinical and operational leaders remain accountable for implementing workflows and achieving performance expectations within their departments.

1. Clinical Quality Performance Management

• Maintain an inventory of organizational clinical quality measures, targets, accountable leaders, reporting frequency, and current performance status.
• Review performance for UDS, HEDIS, value-based, population health, CCBHC, and other assigned clinical quality measures at established intervals.
• Identify measures, sites, providers, populations, or workflows performing below target and determine whether formal improvement activity is required.
• Conduct direct performance reviews with clinical and operational leaders and clearly define required actions, owners, and follow-up dates.
• Distinguish data-quality concerns from true clinical-performance gaps and coordinate resolution with Quality Analytics, BI, IT, EMR vendors, or clinical leadership as appropriate.
• Escalate persistent or significant clinical quality gaps to the CMO and CQO and applicable clinical leadership.
• Conduct routine and targeted chart audits to validate compliance with UDS, HEDIS, value-based care, preventive care, and other clinical quality measure requirements.
• Review medical record documentation to identify care gaps, documentation deficiencies, workflow breakdowns, and opportunities for performance improvement.
• Validate numerator and denominator compliance for assigned clinical quality measures and collaborate with Analytics, Informatics, and Clinical Operations to resolve discrepancies.
• Develop and maintain provider-specific and site-specific audit findings, recommendations, and corrective action plans.
• Monitor implementation of corrective actions resulting from chart audits and evaluate effectiveness through follow-up review.
• Analyze audit trends and present findings to clinical leadership, committees, and providers as appropriate.

2. Provider Performance Improvement & Clinical Workflow Optimization

The Clinical Quality Manager is responsible for directly partnering with physicians, advanced practice providers, nursing/clinical leadership, and clinical support teams to improve performance on assigned clinical quality measures.

Responsibilities include:

• Meet directly with providers and clinical teams to review individual, site-level, and organizational performance on UDS, HEDIS, value-based, preventive care, and other assigned clinical quality measures.
• Translate measure specifications into clear, practical expectations for providers and clinical staff.
• Identify provider-specific and workflow-specific barriers contributing to performance gaps.
• Develop targeted improvement plans for providers, sites, or clinical teams performing below established goals.
• Teach and reinforce clinical workflows necessary to appropriately meet quality-measure requirements, including required screening, documentation, follow-up, referral, medication, coding/documentation, and other applicable workflow components.
• Conduct or coordinate provider and clinical-team education when measure specifications or required workflows change.
• Partner with clinical leadership to standardize workflows across providers and sites when variation is contributing to performance gaps.
• Conduct direct workflow observation when necessary to determine why established processes are not producing expected results.
• Use patient-level gap lists and performance reports to work directly with providers and care teams on closing identified care gaps.
• Establish follow-up periods after provider education or workflow intervention and evaluate whether performance improves.
• Identify when poor measure performance is related to workflow, documentation, data capture, provider practice, patient factors, or system configuration and route the issue to the appropriate responsible party.
• Escalate persistent provider-level performance concerns to the appropriate clinical leader when education, coaching, and workflow intervention have not resulted in improvement.
• Coordinate with Quality Analytics to ensure provider performance information used for improvement activities is accurate and actionable.
• Coordinate with IT/Informatics/EMR resources when clinical workflows or documentation tools require modification.

3. Quality Improvement Program & Methodology

• Establish and maintain a standardized organizational methodology for clinical quality improvement, including baseline measurement, defined aim, intervention, responsible owner, monitoring frequency, and outcome evaluation.
• Personally lead complex, high-priority, or organization-wide clinical quality improvement initiatives.
• Determine when a performance gap requires a formal QI project, focused workflow intervention, provider-level action, education, or other response.
• Ensure QI initiatives use measurable objectives and do not close based solely on completion of an activity.
• Evaluate whether interventions produce sustained improvement and modify strategies when results do not improve.
• Maintain a centralized portfolio of active clinical QI initiatives and their status.

4. UDS, HEDIS & Preventive Care Improvement

• Serve as the Quality lead for improvement activities related to UDS clinical measures and assigned HEDIS/value-based measures.
• Review measure performance with clinical leadership at an established frequency and identify priority opportunities for intervention.
• Partner with Quality Analytics/BI to validate measure definitions, denominator/numerator logic, source systems, and reporting concerns before launching interventions.
• Develop provider-, site-, or population-specific improvement strategies when performance variation is identified.
• Coordinate with care management, clinical operations, providers, and support teams to implement interventions.
• Monitor whether interventions improve measure performance and escalate unresolved workflow or accountability barriers.

5. Population Health, Care Management & Referral Quality

• Lead Quality improvement support for population health, preventive care, SDOH, care coordination, referral loop closure, and transitions-of-care performance.
• Use Care Management subcommittee findings and data to identify opportunities requiring structured QI intervention.
• Partner with accountable operational leaders to define measurable corrective or improvement actions.
• Evaluate effectiveness of interventions and recommend additional action when performance does not improve.
• Ensure Quality supports improvement methodology without assuming day-to-day ownership of care management or referral operations.

6. Clinical Workflow & Documentation Improvement

• Evaluate clinical workflows when performance data, audits, incidents, or regulatory findings suggest a process contributes to poor quality outcomes.
• Facilitate workflow mapping and root/contributing-factor review for clinical performance problems.
• Develop clear recommended workflow changes in collaboration with clinical and operational subject-matter experts.
• Coordinate implementation expectations with responsible leaders and establish measures to determine whether the workflow change is effective.
• Ensure clinical workflow changes are incorporated into training, tools, or policies when indicated.

7. Provider & Site Performance Review

• Establish a standardized process for reviewing provider- and site-level clinical quality performance when reliable data are available.
• Prepare focused performance summaries identifying measures below target, trends, and required actions.
• Conduct or facilitate performance discussions with clinical leadership and applicable providers.
• Document agreed improvement actions, accountable owners, and follow-up dates.
• Escalate repeated failure to implement agreed clinical quality actions through the appropriate leadership structure.

8. Clinical Quality CAPs & Improvement Actions

• Lead the clinical improvement component of CAPs when deficiencies relate to clinical performance or workflow.
• Define measurable improvement actions and outcome measures in collaboration with accountable clinical/operational leaders.
• Monitor progress and determine whether clinical interventions demonstrate improvement.
• Coordinate with Regulatory/QA when the clinical QI work is part of a formal regulatory CAP.
• Coordinate with Risk when patient-safety trends require structured clinical improvement.
• Do not close clinical improvement actions based solely on training completion when outcome monitoring is required.

9. Governance & Reporting

• Serve as the primary Quality representative for clinical performance improvement within the Care Management subcommittee and other assigned governance forums.
• Present clinical quality performance, active QI initiatives, barriers, outcomes, and recommendations to QIC.
• Prepare or contribute to Board clinical quality reporting according to the established governance calendar.
• Ensure committee reporting focuses on performance, analysis, actions, and outcomes rather than data presentation alone.
• Track Quality-owned follow-up actions resulting from committee and QIC review.

10. Staff Management

• Establish the Clinical Quality Improvement Specialist's recurring work plan and assigned QI portfolio.
• Assign performance reviews, QI follow-up, project documentation, provider/site outreach, and other execution activities.
• Review Specialist work products for accuracy, completeness, and appropriate QI methodology.
• Provide coaching and clear performance expectations.
• Ensure cross-training and written procedures exist for recurring clinical quality processes.

Required Recurring Deliverables

Deliverable

Minimum Expectation

Clinical Quality Measure Inventory/Scorecard

Maintained continuously; formally reviewed at least monthly

Priority Measure Improvement Plans

Maintained for measures requiring formal intervention

Active QI Project Portfolio

Updated continuously; formally reviewed monthly

UDS/HEDIS Performance Review

According to established reporting cadence

Provider/Site Quality Performance Reviews

According to established clinical leadership cadence

Clinical QI Project Reports

Completed for significant projects with baseline, intervention, results, and next steps

Care Management Committee Quality Report

Each applicable meeting

QIC Clinical Quality Report

According to QIC schedule

Provider Quality Performance Reviews & Improvement Plans

Routine provider-level review of assigned measures; targeted improvement plans, education, and follow-up for identified performance gaps

Clinical Quality Workflow Education

Completed when new workflows are implemented, measure requirements change, or performance review identifies workflow deficiencies

Role Boundaries

This position does not:

• Own day-to-day clinical operations or staffing.
• Replace provider or clinical leader accountability for performance.
• Produce or manipulate source data that belongs to Analytics/BI when validated reporting infrastructure is available.
• Own regulatory interpretation or regulatory evidence management.
• Own routine incident management or risk investigations.
• Treat completion of education, meetings, or outreach as evidence of improved clinical performance without outcome measurement.

Performance Expectations

• All priority clinical quality measures have a defined target, accountable leader, reporting cadence, and current performance status.
• Providers and clinical teams with identified performance gaps receive documented feedback, education, workflow support, and follow-up rather than performance data being distributed without an active improvement intervention.
• Provider/site interventions are followed by reassessment of performance to determine whether the intervention resulted in measurable improvement.
• Measures materially below target have documented analysis and an improvement plan when indicated.
• Active QI projects contain a baseline, measurable aim, defined interventions, responsible owners, monitoring plan, and outcome evaluation.
• Clinical quality performance is reviewed with accountable leadership according to the established cadence.
• Persistent performance barriers are documented and escalated rather than remaining indefinitely in routine follow-up.
• Significant QI initiatives are evaluated for effectiveness and adjusted when interventions do not produce improvement.
• QIC and governance reporting is completed according to schedule and includes analysis and recommended action.

Qualifications

Education & Licensure

Required

• Bachelor's Degree in Nursing, Public Health (MPH), Healthcare Administration (MHA), or related field.

Preferred

• Active, unrestricted Registered Nurse (RN) license in the State of Florida.
• Master's Degree in Nursing (MSN), Public Health (MPH), Healthcare Administration (MHA), or related field.
• Certified Professional in Healthcare Quality (CPHQ).
• Lean Six Sigma Green Belt or higher.

Experience

Required

• Minimum five (5) years of progressively responsible experience in healthcare quality improvement, population health, clinical operations, care management, case management, performance improvement, or related healthcare setting.
• Experience conducting clinical chart audits and medical record reviews.
• Experience interpreting clinical documentation and validating compliance with established quality measure specifications.
• Experience working directly with physicians, advanced practice providers, nurses, and care teams to improve quality outcomes and close care gaps.
• Experience analyzing clinical performance data and implementing targeted performance improvement initiatives.
• Experience within a Federally Qualified Health Center (FQHC).
• Experience with HRSA Uniform Data System (UDS) reporting.
• Experience with HEDIS, Stars, Value-Based Care, and Managed Care quality programs.
• Experience leading provider education, physician engagement, and clinical workflow improvement initiatives.

Preferred

• Experience utilizing Greenway Intergy, NextGen, or similar electronic health record systems.

Knowledge, Skills & Abilities

• Thorough knowledge of clinical quality measures, including UDS, HEDIS, preventive care, and chronic disease management metrics.
• Strong knowledge of clinical documentation standards and medical record auditing principles.
• Ability to conduct independent chart audits and identify documentation, workflow, and performance improvement opportunities.
• Ability to effectively educate, coach, and influence providers regarding clinical quality performance and care gap closure.
• Knowledge of evidence-based clinical practice guidelines and quality improvement methodologies.
• Strong analytical, reporting, and presentation skills.
• Ability to lead multidisciplinary clinical improvement initiatives and drive measurable outcomes.

Advanced proficiency in Microsoft Excel and quality performance reporting tools.

Benefits:

✅ 100% Paid Health Insurance (Employee Base Plan)

✅ 100% Employer-Paid Basic Life Insurance

✅ Dental, Vision, Short-Term Disability (STD), Long-Term Disability (LTD), Secondary Health Insurance, and Other Voluntary Benefit Plans

✅ 403(b) Retirement Plan with Employer Matching

✅ Paid Time Off (PTO)

✅ Paid Holidays

✅ Tuition Reimbursement

✅ Student Loan Forgiveness Opportunities

✅ Employee Referral Bonus Program

✅ Potential HRSA Student Loan Repayment for eligible licensed positions*

✅ Opportunities for Career Growth and Professional Development

*Certain licensed positions working in qualifying outpatient settings may be eligible for the HRSA National Health Service Corps Loan Repayment Program . Eligibility is subject to HRSA requirements and position responsibilities and will be confirmed during the hiring process.

Banyan Health is an Equal Opportunity Employer committed to providing equal employment opportunities to all qualified applicants and employees. We do not discriminate based on race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local laws.