Quality Improvement Manager

Job Description

Job Description

The Quality Improvement Manager serves as an operational leader of the Hopebridge Quality Department and is responsible for coordinating, implementing, monitoring, and sustaining the organization's quality strategy under the direction of the Vice President of Quality. This role provides oversight and support across all quality functions, including quality improvement initiatives, regulatory readiness, patient safety and risk mitigation, patient experience, quality-related audit preparedness, quality reporting, performance monitoring, corrective action planning, and governance activities. 

As the primary direct report to the VP of Quality, this individual acts as a trusted partner responsible for translating departmental strategy into measurable outcomes, leading cross-functional improvement projects, facilitating quality committees, maintaining organizational quality reporting systems, and ensuring quality initiatives are embedded into day-to-day operations across the enterprise. 

The Quality Improvement Manager serves as a catalyst for continuous improvement by leveraging data, Lean Six Sigma methodologies, project management principles, and collaborative leadership to improve patient outcomes, operational performance, regulatory compliance, and organizational effectiveness.  Responsibilities Enterprise Quality Improvement Leadership  

• Lead and coordinate cross-functional quality improvement initiatives across clinical, operational, compliance, and support functions. 
• Utilize Lean Six Sigma, DMAIC, PDCA, and change management methodologies to drive measurable improvements in quality, efficiency, patient outcomes, and regulatory performance. 
• Facilitate project planning, execution, monitoring, and sustainability activities to ensure improvements are sustained over time. 

Quality Governance & Strategy Execution  

• Coordinate Quality Governance, Quality Oversight, and quality committee activities, including agendas, reporting, and action item follow-up. 
• Support execution of the organization's quality strategy and monitor progress toward departmental and enterprise goals. 
• Prepare executive-level presentations, scorecards, dashboards, and quality reports for senior leadership and governance committees. 

Quality Measurement, Analytics & Reporting  

• Develop and maintain quality scorecards, dashboards, KPIs, and performance monitoring tools. 
• Analyze quality, safety, compliance, patient experience, and operational data to identify trends, opportunities, and emerging risks. 
• Produce recurring reports and actionable recommendations that support data-driven decision making. 

Regulatory Readiness, Audit & Compliance Support  

• Coordinate internal audits, payor audits, accreditation reviews, and regulatory readiness activities as each relates to quality of care or quality improvement initiatives. 
• Monitor corrective action plans and ensure timely implementation and closure of improvement activities. 
• Support mock audits, gap assessments, and ongoing monitoring of quality compliance risks and recurring findings. 

Patient Safety & Risk Management  

• Monitor incident reporting trends and assist with root cause analyses and corrective action development. 
• Track quality-related risk mitigation activities and support organizational patient safety initiatives. 
• Maintain documentation and reporting related to significant event reviews, investigations, and safety improvement efforts. 

Patient Experience & Quality of Care Improvement  

• Monitor patient satisfaction, NPS, grievance, and service recovery data. 
• Identify opportunities to improve the patient and family experience across the care journey. 
• Partner with operational and clinical leaders to implement improvements that enhance quality of care and patient outcomes. 

Quality Project Portfolio Management  

• Manage the Quality Department portfolio and project tracking systems. 
• Monitor project status, milestones, dependencies, risks, and outcomes. 
• Ensure successful transition of projects from implementation to Business As Usual (BAU), including sustainability planning and ongoing monitoring. 

Quality Operations & Organizational Improvement  

• Coordinate Quality Department workflows, priorities, and deliverables. 
• Develop and maintain quality-related SOPs, templates, tools, and standard work. 
• Facilitate stakeholder meetings and maintain project and governance documentation. 
• Train and coach organizational leaders on quality improvement methodologies and continuous improvement practices. 
• Promote a culture of accountability, standardization, and data-driven decision making throughout Hopebridge. 

Required Skills Education  

• Bachelor's degree required in Healthcare Administration, Public Health, Nursing, Business Administration, Quality Management, Industrial Engineering, Organizational Leadership, or related field. 
• Master's degree preferred. 

Experience  

• 5+ years of healthcare quality, compliance, operations, performance improvement, project management, or related experience. 
• Demonstrated experience leading cross-functional improvement initiatives. 
• Experience interpreting and presenting performance metrics. 
• Experience supporting audits, corrective action plans, regulatory compliance, or accreditation activities preferred. 
• Experience in ABA, autism services, behavioral health, pediatric healthcare, or multi-site healthcare operations preferred. 

Preferred Certifications  

• Lean Six Sigma Green Belt required within 12 months. 
• Lean Six Sigma Black Belt preferred. 
• Certified Professional in Healthcare Quality (CPHQ) preferred. 
• PMP certification preferred. 

Key Performance Indicators  
The Quality Improvement Manager may be accountable for: 

• Completion rate of strategic quality initiatives. 
• Timeliness of corrective action plan implementation. 
• Reduction in repeat quality-related audit findings. 
• Quality KPI performance improvement. 
• Sustained project outcomes following BAU transition. 
• On-time quality reporting and governance deliverables. 
• Reduction in incident and safety trend recurrence. 
• Improvement in patient satisfaction and grievance resolution metrics. 
• Stakeholder satisfaction with Quality Department services. 

Position Success Profile  
The ideal candidate is equal parts: 

• Quality Improvement Leader 
• Project Manager 
• Data Analyst 
• Governance Coordinator 
• Patient Safety Partner 
• Regulatory Readiness Lead 
• Patient Experience Champion 

This role essentially becomes the operational engine of the Quality Department, allowing the VP of Quality to focus on executive strategy, enterprise influence, governance, major audits, payor relationships, and department growth while ensuring all quality functions remain coordinated, visible, and effective.