Program Manager, Internal Quality Audit

Harris Health System, Inc.; Bellaire (TX); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Telecommute eligibility

Job summary

Harris Health is seeking a seasoned professional to lead the internal quality system audit program. You will collaborate with leadership, medical staff, and departments to ensure regulatory and accreditation standards are met across the quality management system.

Responsibilities include risk assessment, procedure development, and ongoing consultation on quality improvement tools. Strong nursing expertise and data-driven decision making are essential.

Qualifications

• Bachelors in Nursing and Texas RN license required; Masters preferred.
• Minimum 5 years in quality auditing and quality management systems.
• Experience with outcomes management, risk assessment and data reporting.

Responsibilities

• Manage internal quality system audit program with leadership and staff.
• Identify risks and establish audit responsibilities and procedures.
• Monitor and improve audit program; report results to management.
• Provide ongoing education on QM standards to leaders and staff.

Skills

Nursing knowledge

Quality auditing

Project management

Data analysis

Education

Bachelor's in Nursing

RN license (Texas)

Masters preferred

Tools

Word

Excel

Access

Job description

Harris Health is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor Harris Health's robust network of 39 clinics, health centers, specialty locations and virtual (telemedicine) technology. Harris Health is among an elite list of health systems in the U.S. achieving Magnet® nursing excellence designation for its hospitals, the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty, residents and researchers from Baylor College of Medicine; McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth); and The University of Texas MD Anderson Cancer Center.

At Harris Health, we prioritize the well‑being of our most valuable asset--our people--ensuring a culture of compassion, collaboration and excellence in serving Harris County's most in need. With integrity and accountability at our core, we commit to 'leading with love', embodying our dedication to quality care, education, and a steadfast respect for every individual's contribution to our mission.

JOB SUMMARY:

This position is responsible for managing the internal quality system audit program of Harris Health System in collaboration with leadership/management, medical staff and other department staff to evaluate and determine the effectiveness, efficiency and compliance to regulatory and accreditation standards of the established HHS quality management system, which includes: 1) establishes the extent of the audit program; 2) identifies and evaluates risks for the audit program; 3) establishes the audit responsibilities; 4) establishes procedure for the audit program; 5) monitors, reviews, and improves the audit program. The project manager manages the overall implementation of the audit according to objectives; reports to management audit results as part of the management review process; oversees overall competence and evaluation of internal auditors; as well as providing ongoing consultation and education with management and other organization leaders on the application of quality management system standards relevant to the achievement of the quality objectives.

Work requires strong clinical nursing expertise and an understanding of patient care standards/practices and applicable accreditation and regulatory requirements. Considerable knowledge of internal quality system auditing, project management and quality improvement concepts, methodologies and tools, and of the importance of data to performance improvement processes (e.g. establishing baseline, providing objective measurement, determining the degree of the problem, showing variation/causes of variation, identifying root causes, developing appropriate solutions, etc) is also required. Also be accountable for the success of the quality system audits. Duties performed involve weighing and evaluating many factors requiring judgment, analytical ability and problem-solving in dealing with complex data and situations.

MINIMUM QUALIFICATIONS:

1. 1.Education/Specialized Training/Licensure: Bachelors Degree in Nursing or other healthcare related field; Masters degree in healthcare preferred; Current Texas RN license required.
2. 2.Work Experience (Years and Area): 5 years of related work experience, including experience in internal quality auditing, quality management system standards implementation, outcomes management, risk assessment, data analysis/reporting and management of clinical work teams.
3. 3.Knowledge of Microsoft Word, Excel and Access; typing and organizational skills. Must exhibit strong people and analytical skills.
4. 4. Equipment Operated: Photocopier, Personal Computer, 10-Key Calculator, Fax Machine, Recorder, Window-Based Software Programs, etc.

SPECIAL REQUIREMENTS:

1. 1.Communication Skills:
   • Must possess high-level interpersonal communication skills to interact effectively with all levels of personnel within the organization.
   • Above Average Verbal (Heavy Public Contact)
   • Writing /Composing (Correspondence/ Reports)
2. 2.Other Skills: Analytical, Design, Mathematics, Research , Statistical
3. 3.Work Schedule: Weekends, Eligible for Telecommute
   • a.May require extended hours in addition to weekends/ holidays for special projects.
4. 4.Other Requirements:Self-directed with organizational and priority setting skills.