Job Details

Salary Range: $87,500 to $95,000 Annually

Summary:

Under the direct supervision of the Quality Management/Risk Management Director, the Quality Management/Risk Management Manager is responsible for providing management support to the Agency's Quality Management/ Risk Management Program, to include The Joint Commission Ambulatory Program, The Joint Commission Patient-Centered Medical Home Certification, Quality Management Trainings, Quality Management surveys, clinical risk management program, QM/RM staff supervision, and other related projects as assigned, and prepares Quality Management/Risk Management narrative and data reports.

DUTIES AND RESPONSIBILITIES:

• Responsible for providing support for the effective management of the Quality Management/ Risk Management Program in accordance with Agency policy and standards, and provides recommendations for continuous improvement, and supervises QM/RM staff as assigned
• Responsible for managing the Agency's The Joint Commission (TJC) program, assures the Agency consistently has current TJC Ambulatory Care standards and TJC Patient Centered Medical Home (PCMH) standards available at all health center sites, assures distribution of current TJC standards to department managers, and other key staff, provides education and training to staff on TJC Ambulatory Care and PCMH Standards.
• Responsible for managing TJC unannounced survey process to include e.g., assures a current TJC unannounced readiness assignment is on file at all health center sites and is distributed to all assigned staff, assures TJC unannounced readiness assignment is inclusive of TJC arrival on day one and through the exit conference on day three, checks TJC website daily for the unannounced survey and alerts staff, assures TJC staff assignments are current and available at all health center sites, and to all department managers and key staff.
• Responsible for managing continuous preparation for TJC with the QM/RM Director e.g., manages, implements and reviews TJC Periodic Performance Review, assures Periodic Performance Review documentation is available on file and distributed to department managers and other key staff and to TJC,, coordinates submission of Corrective Action Plans (CAPs) on Periodic Performance Review Survey findings from managers to the QM/RM Director, and to TJC, monitors CAPs to assure progress with compliance within designated timelines.
• Responsible for collaboratively working with the Chief Medical Officer, and other key managers on PCMH provider empanelment, works with the QM/RM Director, the Chief Medical Officer and other key staff with implementation and compliance with TJC Ambulatory Care and PCMH standards.
• Responsible for collaborating with key management staff with management of TJC Ambulatory Care and PCMH mock surveys to include e.g. mock survey planning and scheduling, mock survey findings and mock survey CAP monitoring, and assists with and participates in other Agency Program audits/surveys as assigned.
• Responsible for actively participating in the Agency's Education Program pertaining to Quality Management/Risk Management and assists with and coordinates the scheduling of QM trainings including e.g., TJC and PCMH webinars, the annual staff skills competency training, the annual Norcal Risk Management training and other related training and webinars as assigned.
• Responsible for managing the clinical risk management functions of the program e.g., the incident report process to include coordinating, monitoring, tracking and data reporting, and for managing the Agency's clinical indicators survey process to include monitoring for compliance, prepares finding reports, makes presentations on findings, works with the Chief Medical Officer and, clinical staff to continually improve clinical indicator compliance.
• Responsible for active participation in the Improving Organizational Performance Program, to include The Joint Commission, Quality/Risk Management Program, Infection Control Program, Safety Program, and Emergency Preparedness Program, and complies with these program expectations, policies and regulations.
• Responsible for completing TJC and other QM/RM related narrative and data reports, chairs QM/RM related committees as assigned and performs other related QM/RM duties as assigned.

• Bachelor's Degree in a health related field required. Master's degree in health care or related field preferred.
• Four (4) years' experience in the hospital and/or ambulatory clinic and/or public health setting to include progressively responsible team leadership and supervision experience.
• Knowledge of The Joint Commission Ambulatory Health Care Standards, The Joint Commission Patient Centered Medical Home Standards, and their survey process, and knowledge and experience with other healthcare program audit/surveys.
• Effective verbal and written communication skills, ability to write clear concise reports, and ability to perform educational presentations and trainings.
• Proficient in the use of Microsoft Office (Word, Excel, Outlook, and PowerPoint).
• Ability to follow instructions and directions and respond accordingly within scope of responsibility.
• Knowledge of Electronic Health Records and experience with i2i Tracking.
• Ability to work well with others including the professional clinical team in a professional team oriented environment.
• Ability to maintain confidentiality and incompliance with Health Insurance Portability and Accountability Act (HIPAA).
• Valid California Driver's License, access to an automobile, and state-required auto liability coverage.