Quality Manager

100 Lawrence Memorial Hospital; City of Rochester (NY); On-site; USD 90,000 - 140,000; Full time

Benefits offered by this job

Tuition reimbursement

Professional development and recognize

Excellent benefits

Job summary

LMH Health seeks a Quality Manager to oversee regulatory readiness, quality measurement, public reporting and pay-for-performance initiatives. You will guide system design for end users, ensure compliance with CMS and accreditation standards, and mentor staff while driving performance improvements.

You will collaborate with IT and analytics, lead ongoing competency development, and align projects with LMH Health’s strategic plan to promote safety and high reliability across the organization.

Qualifications

• Master’s degree or equivalent in nursing, public health, health administration, or health related field required.
• Current applicable licensure (ex. RN, etc.).
• Five years of relevant acute-care hospital experience in quality, patient safety, regulatory and accreditation or equivalent; certification with CPHQ and/or CPPS or willingness to obtain within 24 months.
• Demonstrated supervisory/leadership experience.
• Yellow Belt in Lean Six Sigma or willingness to obtain within 12 months.
• Strong professional communication, verbal and written; clear and effective across diverse audiences.

Responsibilities

• Directs team to ensure CMS quality programs and reporting measures follow the latest regulations.
• Leads validation of MIPS quality measures for hospital and providers; MIPS value pathways.
• Keeps up-to-date on pay-for-performance programs (VBP, HAC, HRRP, MIPS) and reports to stakeholders.
• Reviews CMS data/reports for accuracy and opportunities; informs improvements.
• Leads strategic teams (sepsis, glycemic control, mortality, readmissions, patient safety).
• Collaborates with IT/Data Analytics to ensure data accuracy for internal use and reporting.
• Provides regulatory guidance (CMS, The Joint Commission) and ensures compliance.

Skills

Leadership

Communication

Education

Master’s degree or equivalent in nursing/public health/health administration

Current applicable licensure

CPHQ/CPPS certification or willingness to obtain within 24 months

Lean Six Sigma Yellow Belt

Job description

Something special starts here. You can’t define it, but you know it when you see it: the difference between an average life and the good life. When your cup is full – with joy, purpose and lifelong health – it shows. At LMH Health, we are all about healthy people, healthy communities and healthy futures, and that makes us your destination for an exceptional career. From flexible, work-life harmony to competitive pay and great advancement potential, find everything you’re looking for at LMH Health.

You'll find everything you’re looking for at LMH Health: Join a team that cares about the community.

• Tuition reimbursement to support continuing education
• Professional development and recognition
• Excellent benefits

We’re looking for you.

Job Description

JOB SUMMARY

The Quality Manager is responsible for overseeing regulatory readiness, quality measurement, public reporting and pay-for-performance programs and initiatives. . Serves as a consultative resource in clinical design of systems for end users with the purpose of driving quality outcomes. As the hospital expert in regulatory and reporting programs this position will serve as a resource to staff and key stakeholders in ensuring compliance to the latest quality mandates from regulatory bodies. As a key leader in the Quality department, this position will be responsible for interpreting applicable regulatory specifications, identifying organizational regulatory requirement gaps, overseeing the collaboration with key stakeholders to guide improvements activities for compliance. The position is responsible for continuous collaborative learning, mentoring direct reports and other staff of the department, maintaining competency and identifying and supporting performance improvement projects and activities throughout the organization through education, planning and project oversight.

ESSENTIAL JOB RESPONSIBILITIES

• Directs team to ensure CMS quality programs, Inpatient Quality Reporting (IQR), Outpatient Quality Reporting (OQR), are followed including abstracting and reporting measures (human, electronic, claims) with the most up-to-date regulations.
• Directs team that participates in the implementation, validation of MIPS quality measures for Eligible Hospital and Eligible Providers; and MIPS value pathways.
• This position stays up-to-date on the pay-for-performance programs that include but are not limited to: Hospital Value-Based Purchasing (VBP) Program, Hospital Acquired Conditions (HAC) Penalty Program, and Hospital Readmission Reduction Program (HRRP), Merit-based Incentive Payment System (MIPS) with real time review and reporting to key stakeholders in the organization.
• Reviews and analyzes data and reports from CMS to ensure accuracy, identifying opportunities, and reporting to key stakeholders.
• Leads or participates in organization strategic teams, such as, sepsis, glycemic control, mortality, readmissions, patient safety indicators.
• Establishes mechanisms for proactive identification and correction of regulatory issues.
• Collaborates with Information Technology and Data Analytics to ensure accuracy of data in the department both for internal use and public reporting as applicable.
• Acts as a content expert and provides direction with regulatory compliance (such as CMS and The Joint Commission).
• Responsible for understanding and reporting additional programs as requested by the organization such as Blue Cross Blue Shield Kansas Hospital Quality Reporting Program.
• Applies performance improvement methodologies and tools to projects (such as, but not limited to Lean, Six Sigma, statistical process control, DMAIC, FMEA, RCA, process mapping, cause and effect diagrams).
• Understands LMH Health’s strategic plan and aligns improvement efforts with the strategic goals of the organization.
• Promotes a culture of quality, safety, high-reliability, patient and staff engagement, and performance excellence.
• Directly supervises Quality specialists and accreditation coordinator.
• Performs other duties as needed or assigned.

JOB QUALIFICATIONS

• Required: Master’s degree or equivalent experience in nursing, public health, health administration, or health related field required
• Current applicable licensure (ex. RN, etc.)
• Five years of relevant acute-care hospital experience in quality, patient safety, regulatory and accreditation or an equivalent combination of education and experience which would demonstrate the required knowledge, skills and abilities may be qualifying; Certification with CPHQ and/or CPPS; or willingness to obtain the certification within 24 months of hire.
• Demonstrated experience in supervisory/leadership.
• Yellow Belt in Lean Six Sigma or willingness to obtain within 12 months of hire date.
• Demonstrated professional communication: verbal and written.
• Clear and effective communication to diverse audiences.
• Possesses expert leadership skills and maturity in managing difficult situations and conducting crucial conversations.

Preferred:

• Advanced knowledge of data analysis and utilization (including Microsoft Excel, Word and Power Point).
• Green Belt in Lean Six Sigma
• Basic knowledge of statistics and statistical methods of analysis.

Our Cultural Beliefs

People First Integrity Matters Better Together At LMH Health, we value inclusion and diversity.

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.

Find a career you will love.

At LMH Health, great care begins with great people. That’s why we hire people driven by excellence, energized by community, and inspired to make a difference — just like you.