Manager - Quality Program

0090 Presbyterian System Services; Espanola (NM); Hybrid; USD 76,000 - 129,000; Full time

Job summary

Presbyterian Española Hospital in Espanola, NM is seeking a Manager for the Quality Program to lead quality improvement initiatives, regulatory readiness, and patient safety programs that support clinical outcomes and operational excellence.

This role partners with physicians and interdisciplinary teams to foster continuous improvement and oversee quality metrics, accreditation readiness, and data-driven decision making.

Qualifications

• Bachelor's degree in nursing or related clinical field is required.
• Master's degree is preferred.
• Licensed RN preferred.
• 3-5 years experience in health care quality required.
• Clinical Quality experience with emphasis on data and measurement preferred.
• Prior leadership experience preferred.
• CPPS, CPHQ or other quality certification preferred.

Responsibilities

• Develop, monitor and support the facility QAPI program to ensure regulatory requirements.
• Analyze QAPI data and report data to appropriate committees/groups.
• Provide clinically pertinent perspective in development of clinical information and measurement processes.
• Participate in development, collection and reporting of clinical performance measurements.
• Manage regulatory and accreditation preparation activities at the facility level.
• Lead and support quality initiatives and infection control programs.

Skills

analytic

customer service

MS office

negotiation

presentation

reporting

verbal communication

professionalism

written communication

Education

Bachelor's degree in nursing or related clinical field

Master's degree preferred

Licensed RN preferred

CPPS or CPHQ certification preferred

3-5 years health care quality experience

Job description

Location

1010 Spruce Street Espanola, NM 87532-2724

Compensation

Minimum Offer $75,732.80 Maximum Offer $128,960.00

Job Title

Manager - Quality Program

Summary

Lead with Purpose. Inspire Excellence. Make a Difference. Presbyterian Española Hospital is seeking a Manager for our Quality Program to lead quality improvement initiatives, regulatory readiness efforts, and patient safety programs that support exceptional clinical outcomes and operational excellence. The Manager, Quality Program serves as a key leader within the hospital, partnering with physicians, nursing leadership, and interdisciplinary teams to foster a culture of continuous improvement, patient safety, and high reliability. This role is responsible for overseeing quality metrics, accreditation readiness, performance improvement activities, regulatory compliance, and data-driven decision-making to ensure the delivery of high-quality patient care. This role will lead, design and support the quality program including clinical quality, patient safety and continuous readiness to assure quality care and regulatory compliance.

Function as a SME for quality methodologies, facilitating, coaching and supporting quality initiatives. Responsible for goal initiatives, identifying appropriate solutions for clinical initiatives in a timely manner and is actively involved in process redesign and re-engineering. Assist and support PHS quality initiatives. This role is also responsible for the Infection Control, Employee Health and Case Management service programs. This role is based at Presbyterian Española Hospital and features a flexible hybrid schedule, allowing for a combination of on-site and remote work based on business needs. Type of Opportunity: Full time Job Exempt: Yes Job is based: Presbyterian Espanola Hospital Work Shift: Days (United States of America)

Responsibilities

• Develop, monitor and support the facility QAPI program to ensure it meets regulatory requirements, to include infection control, clinical quality and business indicators in conjunction with leadership and the Regional Director of Clinical Quality/Patient Safety.
• Analyze QAPI data and report data to appropriate committees/groups.
• Provide clinically pertinent perspective in development of clinical information and measurement processes in conjunction with the Regional Director of Quality/Safety.
• Participates in the development, collection and reporting of clinical performance measurements.
• Manage regulatory and accreditation preparation activities at the facility level and assist at the PHS level.
• Serves as a lead contact during regulatory surveys, working with the Regional Director of Clinical Quality/Patient Safety.
• Lead and assist facility in establishing and maintaining quality plans, clinical improvement, management of processes and establishing goals and objectives for clinical quality and patient safety initiatives.
• Serve as a resource regarding quality theory and practice, especially as it relates to: development and evaluation of patient safety and quality indicators, application of quality methodologies to quality improvement and regulatory readiness.
• Lead and support clinical quality and patient safety initiatives at the facility and participate in task forces, summits, and work groups as appropriate.
• Conduct risk analysis using established techniques and strategies.
• Conduct RCI/PSI or special cause investigations.
• Prepare, present and maintain short term and long-range quality improvement plans, clinical outcome plans and patient safety plans.
• Manage and direct a team, orient new staff.
• Oversee the outcomes of orientation processes and retention of new hires.
• Address areas of opportunity to meet organizational goals.
• Drive financial components of department operations including budget creation, monitoring, analyzing, report variances in areas of responsibility.
• Responsible for achieving established targets.

Qualifications

• Bachelors degree in nursing or related clinical field or bachelors degree with health care experience required.
• Masters degree is preferred.
• Licensed RN preferred.
• 3-5 years experience in health care quality required.
• Clinical Quality experience with emphasis on clinical quality data and measurement, interdisciplinary support and performance improvement preferred.
• Prior leadership experience preferred.
• CPPS, CPHQ or other quality certification preferred.

Skills

• analytic
• customer service
• MS office
• negotiation
• presentation
• reporting
• verbal communication
• professionalism
• written communication

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits. Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED.

PHS is a drug-free and tobacco-free employer with smoke free campuses.

We’re Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services Here, we’re committed to a different way to make a difference.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, nurses, employees, board members, and volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than one in three New Mexicans. We are part of New Mexico's history and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.