Job Description

POSTING DATE: 7-1-2026

CLOSING DATE: 7-8-2026

WAGE: NEGOTIABLE

GENERAL RESPONSIBILITIES:

This is a full-time position. Under the direction of the Director of S/M Healthcare Services, the Quality Assurance Manager is responsible for a) the coordination, development, implementation, and writing and revising of policies and procedures to meet standards for accreditation of the Health Care organization, b) This includes establishment and monitoring of the quality assurance program, CQI monitors, Patient Satisfaction Survey, Employee Satisfaction Survey, Customer Services, and other related duties.

STANDARD QUALIFICATIONS:

All employees of Stockbridge Munsee Community must meet the following qualification:

1.Must submit to and pass a pre-employment drug and health screening.

2.Must be at least 18 years of age, unless otherwise stated on job description

3.Must maintain an acceptable departmental attendance record

4.Must be able to work weekends, nights, and holidays

5.Must obtain and maintain Elder/Youth License as stated on job description.

DUTIES:

1.Conduct CQI monthly meetings based on an agenda-

• • Follow-up with all the departments/program managers to obtain their CQI completed monitors for the month,
  • Have the program directors/managers present their monitors in the meeting, review them, and have approval by CQI Committee,
  • Take CQI meeting minutes and distribute it among the Committee members within a reasonable time period, and
  • Maintain CQI minutes for quality improvement and Accreditation or recertification purposes,

2. Conduct

• • patient satisfaction survey at regular interval,
  • Employee Satisfaction survey,
  • Customer Services trainings as needed,
  • Annual Employee Education Fair and coordinate with department head managers to develop trainings to meet training requirements.

3.Conduct patient satisfaction/patient experience survey by each provider in the Medical, Dental, Chiropractic, Mental Health, and submit the survey results to CQI Committee and Health Board Meeting for their review and getting direction on improvement of quality of patient care.

4.Conduct special quality improvement Studies, or quick survey for quality assurance purposes or as and when needed by Administration (Health Center Director) or for accreditation/recertification by AAAHC .

5.Coordinate credentialing/privileging of newly hired professional staff and reappointment and renewal of privileging for existing staff.

6.Maintenance of Credentialing files and spreadsheet of dates. Host and provide meeting minutes for credentialing committee.

7.Oversee the enrollment of professional staff in Council of Affordable Quality Healthcare (CAQHC). Maintain providers’ attestation and current documents.

8.Assists Business office in enrollment of professional staff in CMS, and all insurance programs that the Health Center participates in.

9.Services as the SMHWC’s CMS compliance officer.

10.Keep track of CME’s (Continuing Medical Education) by provider using a spread sheet on annual basis.

11.Coordination of policies, procedures, and other activities within the Health Center to facilitate compliance with various standards including those for AAAHC.

12.Assists departments with flow charts visualizing the policies to better understand the work flow.

13.Complete project reports, monthly reports, and other reports as required.

14.Assist with the coordination of quality assurance activities within the Health Center.

15.Develop policy for any operational needs, and follow the process for approval having Legal to review and present them to b) the Health Board, and c) the Tribal Council for final approval.

16.Review the existing policies on regular basis so that they continue to meet the changing operational needs.

17.Organize the polices in a way that is more facilitating for the health center staff to read and refer to when needed.

18.Develop patient information material and assist with coordination of Patient education information.

19.Attend Health Board and Tribal Council meetings as required.

20.Must maintain an acceptable departmental attendance record.

21.

22.Required to attend job related in-service, meetings, and training to maintain professional and technical knowledge.

23.Must adhere to tribal law and other applicable laws as well as tribal personnel policies and procedures.

24.May be required to satisfactorily complete an exam or other testing requirement(s) to determine skill proficiency.

25.The above duties and responsibilities are not an all inclusive list but rather a general representation of the duties and responsibilities associated with this position. The duties and responsibilities will be subject to change based on organizational needs and/or deemed necessary by the supervisor.

QUALIFICATIONS:

1.Must have three (3) years of experience in Health Care Accreditation preferred.

2.Must have completed application for survey and obtained a 3-year certification for a health care accreditation survey such as AAAHC or Joint Commission preferred

3.Must have ability to read regulations (AAAHC and State) and ensure clinic policies are in line with regulatory requirements.

4.Must be able to accurately file documents in and organized manner that allows for the record to be produced when needed.

5.Must be able to keep a schedule to submit documents to different areas at or before the due dates.

6.A High School Diploma or GED is required. An Associates degree or higher is preferred.

7.Must be able to work using Microsoft Office Suites e.g. Word, Excel, Access, Power Point, Visio.

8.Must be able to work with numbers, compile data, analyze data from patient satisfaction survey, QI Studies, Employee Survey etc.

9.Must be able to effectively coordinate and chair working committees.

10.Must have a knowledge of health care/patient care, CQI monitors, and accreditation or recertification process.

11.Must be proficient in writing and will be expected to demonstrate proficiency.

12.Must be able to draft, edit, and finalize procedures required for accreditation.

13.Must be able to maintain confidentiality.

14.Ability to take and transcribe meeting minutes.

15.Must submit and pass a background security check to meet the Elder/Youth License Requirement as it pertains to the position and the location of the department prior to and during the course of employment with the Stockbridge-Munsee Community.

16.Must pass pre-employment drug and health screening. Must adhere to the Tribe’s Drug and Alcohol Free Workplace Policy during the course of employment.

17.Have demonstrated ability to maintain satisfactory working record in any prior or current employment.

18.Must abide by departmental and organizational safety, testing, and uniform guidelines.

19.Must be able to meet physical requirements of position.

20.Must be eligible for coverage under the employer’s liability insurance

PHYSICAL REQUIREMENTS/WORK ENVIRONMENT

1. This position requires a lot of sitting with occasionally stoop, kneel, crouch, and lift and/or move up to twenty-five (25) pounds.

2. Evening and/or weekend is required. Extended hours and irregular shifts may be required.

3. Work environment requires excellent personal hygiene due to working in close proximity to others and in an enclosed area.

4. A Tuberculosis (TB) Screening and/or TB Skin Test may be required.

SUBMIT APPLICATION AND RESUME TO

https://mohican.rec.pro.ukg.net/STO1014MUNSE/JobBoard/24285ec7-5cae-43e8-aeb0-90052d681827

WE ARE A DRUG FREE EMPLOYER.

CANDIDATES MUST PASS DRUG SCREEN

AND REMAIN DRUG FREE.

The Stockbridge-Munsee Community operates as an equal opportunity employer except Indian Preference is given in accordance with the Employee Preference Policy Ordinance as permitted under federal law. Due to broad federal funding and the co-mingling of fiscal resources, all tribal government operations jobs are treated as federally-funded for the purposes of the Employee Preference Policy Ordinance unless specifically identified as not federally-funded.

Although an interview may be granted, this does not determine that the candidate fully meets the qualifications until it is determined by the interview team.

New Position: Tribal Council Approved:

Revised Position: Tribal Council Approved:4-16-19

Revised Position: 08/01/2025 Tribal Council Approved: 08/05/2025