Director of Quality

Sunset Community Health Center; Yuma (AZ); On-site; USD 90,000 - 130,000; Full time

Job summary

Sunset Community Health Center seeks a leader to oversee the Continuous Quality Assurance and Performance Improvement (QAPI) and Risk Management Programs. You will develop policies, manage daily operations, review incident data, and drive system improvements in collaboration with clinical teams.

The role requires a nursing or healthcare administration background, plus management experience in healthcare and knowledge of NCQA/HRSA requirements. Strong coordination across departments is essential.

Qualifications

• Bachelors degree in nursing or healthcare administration.
• Minimum two (2) years of management experience.
• Minimum five (5) years in a healthcare organization.
• Additional education in risk/quality management and The Joint Commission standards preferred.

Responsibilities

• Develops, initiates, maintains, and revises policies and procedures for the general operation of the QAPI and Risk Management Programs.
• Manages day-to-day operations of these programs.
• Reviews, investigates, monitors, and trends incident reports and reports findings to leadership/board.
• Promotes process improvement and risk reduction across departments.
• Oversees chronic disease management program and patient education; facilitates appointment setting and closes gaps in care.
• Collaborates in care coordination of services for patients with chronic conditions.
• Chairs the Policy & Procedure Committee and ensures regulatory requirements are met.
• Facilitates NCQA PCMH recognition and renewal; handles training and submission tracking.
• Participates in committees and reports on quality and risk management initiatives.
• Performs annual evaluation of QAPI and recommends updates.
• Chairs QAPI Work Group for agenda, PDSA initiatives, and quality improvement efforts.
• Coordinates regulatory survey activities (HRSA, ADHS, Joint Commission, CMS, NCQA).
• Works with clinical teams to improve satisfaction for patients, visitors, and staff.
• Develops SH care management/coordination program within HRSA, ADHS, NCQA PCMH, CMS guidelines.
• Performs other related duties as requested.

Skills

Quality Assurance

Performance Improvement

Risk Management

Policy & Procedure

NCQA PCMH

HRSA Compliance

Leadership

Education

Bachelors Degree in Nursing or Healthcare Administration

Masters preferred

Tools

Microsoft Office

Job description

Conference Center
703 S Ave B BLDG A
Yuma, AZ 85364, USA

Description

• Develops, initiates, maintains, and revises policies and procedures for the general operation of the Continuous Quality Assurance and Performance Improvement (QAPI) Program, and Risk Management Program. Manages day-to-day operations of these programs.
• Reviews, assists in investigation, monitors, tracks, and trends incident reports to identify opportunities for system improvement and reports the information to leadership and/or the Board of Directors.
• Collaborates with other departments to promote process improvement and risk reduction strategies in response to complaint/concern data.
• Provides administrative oversight of the chronic disease management program, oversees patient education, facilitates appointment setting, and closes gaps in care.
• Collaborates in care coordination of services to patients with chronic medical conditions.
• Assists in the development of clinical outcome measures, related tracking and monitoring systems and a mechanism to integrate efforts into organization-wide quality initiatives, including value-based care.
• Chairs the Policy & Procedure (P&P) Committee, ensuring organizational leaders are aware of HRSA, ADHS, NCQA, and FTCA P&P requirements.
• Facilitates NCQA PCMH recognition and renewal efforts, including training and application tracking and submission.
• Actively participates in a variety of committees providing information, reports, and recommendations relevant to quality, and risk management.
• Completes an annual evaluation of the Continuous Quality Assurance and Performance Improvement Plan and recommends necessary updates and/or revisions.
• Chairs the QAPI Work Group with primary responsibility for preparing agenda, overseeing PDSA initiatives, and facilitating process and/or quality improvement efforts.
• Facilitates provider and system wide improvement efforts to meet organizational goals and performance requirements.
• Reviews and analyzes quality improvement and risk minimization indicators; prepares follow‑up documentation and implement changes as needed.
• Helps ensure the safety and security of all the people, assets, and processes across the organization.
• Mitigates enterprise risks that may threaten the existence of the company, its reputation and stability.
• Analyzes agency compliance with regulations and other requirement from external organizations, such as the Arizona Department of Health Services (ADHS), OSHA, FTCA, and HRSA.
• Coordinates regulatory survey activities including, but not limited to, HRSA, ADHS, The Joint Commission, CMS, and NCQA.
• Participates in internal and external audit processes.
• Works in partnership with the clinical teams to enhance overall satisfaction for patients, visitors, and employees, including a proactive approach to resolving problems and complaints with respect to care, treatment, rights, and ability to access healthcare services.
• Develops and maintains SH care management/coordination program to improve overall patient care outcomes, within HRSA, ADHS, NCQA PCMH and CMS guidelines.
• Performs other job‑related functions and activities as requested/required.

Supervisory Responsibilities:

Direct Reporting: Nurse Care Manager, Quality Coordinator, Lead Chronic Disease Specialist

Indirectly Reporting: None

Scope of Supervisory Responsibilities: Day to day supervision

EDUCATION and/or EXPERIENCE:
Bachelor’s Degree in nursing or healthcare administration or related field. Masters preferred.
Minimum two (2) years management experience.
Minimum five (5) experience in a healthcare organization.
Additional education in risk/quality management and The Joint Commission standards preferred.

Qualifications

Skills

Required

Basic Computer Skills

Novice

Education

Required

Bachelors or better in Nursing or related field.

High School or better.

Preferred

Masters or better.

Licenses & Certifications

Required

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.