Transplant Quality and Performance Improvement Manager

aah; Ardmore (NC); Hybrid; USD 99,000 - 148,000; Full time

Benefits offered by this job

Hybrid schedule

Benefits eligible

Job summary

Atrium Health Wake Forest Baptist Medical Center is seeking a Transplant Quality and Performance Improvement Manager to lead quality, compliance, and performance improvement for the Solid Organ Transplant Program. The role partners with Nursing leadership and regulatory bodies to ensure ongoing readiness and optimal patient outcomes.

The position requires a Bachelor’s in Nursing (Master’s preferred), CPHQ certification, and three years of management experience in quality roles.

Qualifications

• Bachelor's Degree required in Nursing or other clinical discipline.
• Master's Degree preferred in a health-related field or MBA.
• Active RN license in state; CPHQ certification preferred.

Responsibilities

• Oversee the Transplant Quality Program across pre-, peri-, and post-transplant care.
• Lead regulatory surveys and ensure CMS, UNOS, OPTN, and JCAHO readiness.
• Coordinate PI initiatives and performance improvement projects.
• Develop and monitor scorecards and dashboards for program metrics.
• Provide leadership, training, and QA expertise to transplant teams.

Skills

Quality Improvement

Regulatory Compliance

Leadership

Project Management

Data Analysis

Education

Bachelor's Degree in Nursing

Master's Degree preferred

Tools

EPIC

Microsoft Office

Job description

Department:

37811 Wake Forest Baptist Medical Center - Pre Transplant: Kidney

Status:

Full time

Benefits Eligible:

Yes

Hou rs Per Week:

40

Schedule Details/Additional Information:

Full time - 40 hours per week

Hybrid schedule available

Must obtain CPHQ certification within 2 years of hire

Pay Range:

$47.50 - $71.25

Atrium Health Wake Forest Baptist Medical Center is a key part of our nationally recognized academic health system. Our 885-bed tertiary care hospital houses the region's only children's hospital, burn center, and Level I adult and pediatric trauma centers. The campus is also home to a National Cancer Institute- designated Comprehensive Cancer Center and to clinical centers of excellence in multiple specialties including cardiovascular, brain health and neurology, sports medicine and orthopedics, transplantation and nephrology.

The Medical Center is seeking a Transplant Quality and Performance Improvement Manager to lead quality, compliance, and performance improvement for the Solid Organ Transplant Program. This role oversees a multidisciplinary, data-driven QAPI program spanning all phases of transplant and donation, including pre-transplant, transplant, and post-transplant care for renal, pancreas, and cardiac transplant patients, as well as the LVAD program. The manager serves as the primary contact for regulatory and accreditation agencies and ensures compliance with applicable oversight bodies, including TJC, CMS, UNOS, OPTN, and others as needed. Responsibilities include identifying opportunities to improve quality, safety, efficiency, and patient experience; partnering with nursing leadership to support seamless service line delivery; and leading performance improvement initiatives in collaboration with Patient Safety and Risk Management. The role also provides project management, facilitation, and oversight for quality improvement and patient safety initiatives within Transplant Services. Additional responsibilities include employee performance evaluations, orientation, training, and working closely with medical staff to prepare for current and pending regulatory requirements. Change leadership is a key function of this position.

EDUCATION/EXPERIENCE :

Bachelor's Degree required in Nursing, or other relevant clinical discipline. Master's Degree preferred in a health-related field, or MBA. Must be willing to pursue higher education based on the needs of Transplant Services. Previous experience in quality assurance/performance improvement role required. Three years management experience in a similar role is required. Proficient in the use of Word, Excel, PowerPoint, Visio and EPIC.

LICENSURE, CERTIFICATION, and/or REGISTRATION:

Active applicable state RN License, CPHQ certification

ESSENTIAL FUNCTIONS:

Responsible for the overall administration and coordination of the Transplant Quality Program, serves as the quality expert for Transplant Services.

Demonstrates leadership in the areas of Human Resources, Performance Improvement, Planning, Directing, Financial Management, Continuous quality improvement.

Prepares and maintains materials/documents used for surveys by OPTN, CMS/applicable state Department of Health for transplant centers and for Joint Commission certification.

Works directly with regulatory agencies to ensure compliance. Generates action plans and ensures follow-up. Leads managers and staff to assure continuous readiness for survey with policy and procedure review and revision, mock survey drills, and ongoing education.

Develops/revises/implements plans for response to unannounced surveys/visits.

Develops/revises oversight of all transplant related policies.

Coordinates scheduling of announced visits/surveys.

Prepares and submits reports UNOS reports including annual personnel report, changes in key personnel, and reports requested by the Membership and Professional Standards Committee.

Hospital Chapter leader for Joint Commission readiness team for transplant.

Responsible for maintaining the scorecards/dashboards and other reports used for Quality Assessment and Performance Improvement with the presentations for those meetings.

Organizes and facilitates multi-disciplinary teams to successfully implement performance improvement initiatives to achieve program quality improvement goals.

Annually coordinates a review of the PI indicators defined for each program and makes recommendations for revisions.

Oversee the ongoing medical record reviews, including reviews of documentation required for UNOS and CMS. Collates and submits data related to these reviews to the leadership team and hospital departments as requested.

24-hour accountability for patient safety events and disease transmission events with Director of Transplant Services.

Utilizes Quality tools to determine causes of adverse events.

Develops Quality Improvement Plans.

Performs Root Cause Analysis, leads RCA teams.

Initiates and leads performance improvement teams.

Maintains competency in all organizati