Transplant Quality and Performance Improvement Manager

Atrium Health; Winston-Salem (NC); On-site; USD 110,000 - 140,000; Full time

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 oversees a data-driven QAPI program spanning pre-, peri-, and post-transplant care for renal, pancreas, and cardiac transplant patients, including LVAD program, with responsibility for regulatory readiness and collaboration with senior leadership.

Qualifications

• Bachelor's degree in Nursing or related clinical discipline required; Master's preferred.
• Three years of management experience in a quality/performance improvement role.
• Active RN license and CPHQ certification preferred; proficiency with Microsoft Office and EPIC.

Responsibilities

• Lead the Transplant Quality Program across pre-, peri-, and post-transplant phases.
• Ensure regulatory compliance with TJC, CMS, UNOS/OPTN and Joint Commission standards.
• Develop dashboards, reports, and action plans; coordinate surveys and readiness activities.
• Manage staff performance, training, and initiatives to improve patient safety and outcomes.

Skills

Leadership

Quality improvement

Project management

Regulatory compliance

Data analysis

Communication

Education

Bachelor's degree in Nursing or related clinical discipline

Master's degree preferred

MBA preferred

Tools

Word

Excel

PowerPoint

Visio

EPIC

Job description

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.
• Oversees 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 organizational, departmental, and outside agency safety standards relevant to job performance for business unit and ensures business unit and staff compliance. Maintains systems and processes to ensure continuous compliance with the CMS Conditions of Participation related to QAPI. Directs and identifies needs for OPTN and CMS regulatory requirements, Joint commission specialty certification pay for performance initiatives, and works with payer directed centers of excellence programs.
• Continuously analyzes systems and processes. Develops and implements best practices and appropriate changes to improve outcomes in a timely manner.
• Creates evaluation strategies to monitor performance and determines the need for improvements. Initiates and sets goals for programs and functional area according to the strategic objectives of the organization.
• Ensures program and functional area operations and activities adhere to any legal guidelines and internal policies. Keeps senior management informed with detailed and accurate reports or presentations.
• Develops appropriate communication and communication methods to facilitate the flow of information and maximizes effective communication throughout the program. Communicates services with other departments and vendors as applicable.
• Facilitates and leads monthly quality meetings for solid organ programs, leads transplant executive meeting in absence of the Director.
• Develops, retains, recruits, and leads a talented management/clinical team committed to accomplishing the organizational/business unit goals, objectives, and corporate compliance.
• Recommends, implements, and evaluates plans and systems to capture data and regulatory agency needs.
• Supervises the work and manage performance of assigned staff such as responsibility for work assignment, performance reviews, and personnel change recommendations. This includes transplant financial coordinator team and quality/data teams.
• Participates in various medical center committees, work groups, and task forces as requested, including the hospital emergency preparedness committee to ensure compliance with regulatory requirements.

Skills/Qualifications

Excellent organizational and leadership skills Highly self-motivated professional with ability to work under pressure with tight deadlines Ability to achieve results with a high level of accuracy and attention to detail Demonstrated problem-solving and analytic skills Ability to prioritize and manage multiple projects, work independently and in a matrix-team or collaborative setting Outstanding knowledge of data analysis, reporting and budgeting Working knowledge of all MS Office applications including Word and PowerPoint

Work Environment

Clean, comfortable, office environment

Physical Requirements

Standing, Walking, Sitting, Bending, Reaching with arms, Finger and hand dexterity, Talking, Hearing, Seeing, Lifting, carrying, pushing and or pulling: 20 lbs. maximum