Clinical Quality Improvement Director

US Lawns; Hilo, Northern (HI, KY); On-site; USD 180,000 - 240,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid holidays

Paid vacation and sick days

Retirement program

Employee Assistance Program

Job summary

Hilo Benioff Medical Center in East Hawaiʻi is seeking a Clinical Quality Improvement Director to lead quality, patient safety, and regulatory readiness across acute care, hospital-based long-term care, and ambulatory services.

You will own data inventory for quality reporting, validate reporting, and trace results to source documentation with Epic/BI tools, driving measurable improvements in patient care.

Qualifications

• Bachelor's degree in Healthcare Administration, Public Health, Healthcare Analytics, Nursing or related field; Master’s degree preferred.
• Eight (8) years of progressively responsible work experience in a healthcare setting, including at least four (4) years in a healthcare quality department.
• At least three (3) years of experience in an acute hospital environment.
• At least two (2) years of experience as a supervisor.
• Certified Professional in Healthcare Quality (CPHQ), or ability to attain within twelve (12) months of appointment.

Responsibilities

• Direct hospital quality and regulatory compliance with CMS, Joint Commission, Hawaii requirements, and applicable regulations.
• Lead quality measurement, reporting, and interpretation of hospital quality measures and risk models.
• Analyze and interpret clinical/operational data; develop measurement methodologies with BI tools like Tableau/Power BI.
• Leverage Epic and informatics to extract/quality data; collaborate with IT and clinical leaders to improve documentation.
• Lead quality improvement and care transformation initiatives using data/evidence-based practices.
• Provide strategic leadership and oversight of the quality and analytics staff across East Hawaii Region.

Job description

Job Description

Join Hilo Benioff Medical Center and be part of a team that proudly cares for our friends, family, and neighbors across East Hawaiʻi.

Hilo Benioff Medical Center, the acute care center for East Hawai'i, is hiring a Clinical Quality Improvement Director to lead quality, patient safety, and regulatory readiness across our acute care, hospital-based long-term care, and ambulatory services.

This role is built for someone genuinely fluent in quality data. You will own our data inventory across all quality reporting measures. You will build and validate the reporting yourself and you will be able to trace any result back to the documentation that produced it.

You will participate in the QAPI program, maintain continuous survey readiness, lead patient safety and RCA work, partner with CDI on risk-adjusted outcomes, and supervise the Quality Department. This position reports to the Regional COO with direct board visibility.

This role is fully in-person, based at Hilo Benioff Medical Center.

Key Job Duties:

• Direct hospital quality and regulatory compliance, ensuring adherence to CMS Conditions of Participation, Joint Commission standards, State of Hawaii requirements, and applicable acute care, critical access, and long-term care regulations.
• Lead quality measurement and reporting, including interpretation of hospital quality measures, specifications, exclusions, risk models, and reporting requirements, while understanding their impact on reimbursement, public ratings, and organizational reputation.
• Analyze and interpret clinical and operational data, independently acquiring, validating, joining, and analyzing data; developing measurement methodologies; and using advanced spreadsheets and business intelligence tools such as Tableau or Power BI.
• Leverage Epic and clinical informatics capabilities to extract and evaluate reportable clinical data, develop report specifications, and collaborate with Informatics, IT, and clinical leaders to improve documentation and data capture at the point of care.
• Lead multidisciplinary quality improvement and care transformation initiatives, using data and evidence-based practices to identify opportunities, facilitate performance improvement, communicate results, and drive sustainable improvements in patient care.
• Provide strategic leadership and professional oversight, supervising and developing quality and analytics staff, influencing clinical and medical staff without direct authority, exercising sound judgment with confidential and peer-review information, and working effectively with the communities served by the East Hawaii Region.

Required Qualifications:

• Bachelor's degree inHealthcare Administration, Public Health, Healthcare Analytics, Nursing or related field; Master’s degree preferred
• Eight (8) years of progressively responsible work experience in a healthcare setting, including:
  • At least four (4) years working a healthcare quality department. Such work must have involved participation in the development of policies and procedures to meet State, Federal and other agencies.
  • At least three (3) years of experience in an acute hospital environment
  • At least two (2) years of experience as a supervisor. This includes work experience which demonstrated the applicant's knowledge of and ability to apply the principles, practices, techniques and methods of supervision including: (1) planning, organizing and directing the work of others; (2) assigning and reviewing work; (3) advising others on difficult work problems; (4) timing and scheduling work; and (5) training and developing employees.
• Certified Professional in Healthcare Quality (CPHQ), or the ability to attain the certification within twelve (12) months of appointment.

Preferred Qualifications: Epic reporting experience and long-term care or rural health experience are strongly preferred

Company Description

As the Big Island’s leading providers of inpatient and outpatient care, the East Hawaii Region of Hawai`i Health Systems Corporation (HHSC), consisting of Hilo Benioff Medical Center, Honoka'a Hospital, Ka′u Hospital, Yukio Okutsu State Veterans Home, East Hawaii Medical Group and East Hawaii Health Pharmacy, delivers a full range of services and programs. Our three hospitals include 290 beds and more than 1,900 employees. Our medical staff is comprised of 250 physicians, physician assistants and Advanced Practice Registered Nurses, representing 33 specialties. East Hawaii Health is our network of clinics offering primary and specialty care. Hilo Benioff Medical Center functions as a Level III Trauma Center, which includes the second busiest emergency room in the state, providing 24-hour care and serving more than 50,000 patients annually. Honoka'a Hospital and Ka′u Hospital are designated as Critical Access Hospitals. To learn more about the East Hawaii Region, please watch our Video Yearbook or visit www.hbmc.org, www.honokaahospital.org or www.kauhospital.org.

Benefits

• 13 paid holidays each year (104 hours); 14 (112 hours) during election years*
• 21 paid vacation days (168 hours) per year*
• 21 paid sick days (168 hours) per year*21 paid sick days (168 hours) per year*
• Medical, dental, vision, and prescription plans
• Employee Assistance Program
• Participation in the State of Hawaii’s retirement system
• Potential eligibility for various student loan repayment & scholarship programs

* Rates listed for paid holidays, vacation and sick days are for 1.0 Full Time Equivalent (FTE) positions assigned to 8 hour shifts. Accruals for these benefits are otherwise prorated based on FTE.

About Hilo & The Big Island

Hilo is located on the east side of the island of Hawaii, and has a quaint, old-Hawaii, small town atmosphere. Our island offers amazing rainforests, waterfalls and beaches. The hospital staff is community-oriented and strive to provide competent and compassionate care to every patient that enters our doors.The area is home to the Hawaii Community College, University of Hawaii, Hawaii Volcanoes National Park, excellent schools and convenient shopping.

Pre-Employment Assessments for External Candidates

As part of the recruiting process for this position, external applicants (job applicants NOTemployed byHHSC’s East Hawaii Region)are required to complete pre-employment assessments shortly after application submission. If you are notan employee of the East Hawaii Region of HHSC, youwill receive an email containing assessment instructions. We ask that you complete the assessments within two days of receipt of the request.

Pre-Employment Health Requirements

Offers of employment will be contingent on successfully passing a pre-employment examination, which includes a drug screen and other regulatory medical requirements such as, but not limited to, a tuberculosis (TB) screen. The cost for drug screening and blood draw for QuantiFERON and Titers, shall be borne by the Hawaii Health Systems Corporation.

Equal Opportunity Employer

The East Hawaii Region of Hawaii Health Systems Corporation is a drug free workplace and an Equal Opportunity Employer.