Job Description

Full-time| M-F, 8am-4:30pm could vary due to business needs| Weekly earned wage access is an option.

Job Purpose or Objective(s): The Director of Quality Management is responsible for all quality, risk management, and patient safety related activities within our health organization. You will direct the efforts of all PI initiatives to ensure compliance with regulatory standards. You will support and promote a culture of safety throughout the organization. You will report to the Executive Director.

Primary Tasks:

1. Facilitate alignment between improvement initiatives and the organization’s strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
2. Maintain the facilities system-wide Quality program; to include data collection, aggregating and analyzing data, maintaining policies and procedures and reporting to Administration, Medial Staff, and the Board.
3. Work closely with Clinical and Non-Clinical teams for improvement on overall patient safety, systems-level outcomes, key performance indicators, designs processes for new initiatives, services and other targets identified by Choctaw Nation Health Services Authority leadership.
4. Serves as an internal consultant to Administration, physicians, and staff in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.
5. Focus on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
6. Coordinate, manage and report Core Measures, MACRA and meaningful use measures and other quality metrics as assigned.
7. Collect and report HCAHPS data for the facility.
8. Organize all Quality Management meetings, maintain minutes and make recommendations to the committee based on best practice and current regulatory standards.
9. Conduct internal audits and risk analysis as determined by the Quality Management Committee.
10. Perform other responsibilities as may be assigned.

Required Education and Experience:

• Bachelor’s degree in health or business-related field
• Certified Professional Healthcare Quality (CPHQ), or willingness to obtain
• Knowledge of state and national initiatives related to patient safety and evidenced based guidelines of care
• Knowledge of current trends in scoring regarding JC accreditation and CMS validation surveys
• Experience with data analysis and identification of trends
• Experience in process improvement modalities such as PDCA and Six Sigma
• Six [6] years of experience in quality management and data analysis

1. Facilitate alignment between improvement initiatives and the organization’s strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
2. Maintain the facilities system-wide Quality program; to include data collection, aggregating and analyzing data, maintaining policies and procedures and reporting to Administration, Medial Staff, and the Board.
3. Work closely with Clinical and Non-Clinical teams for improvement on overall patient safety, systems-level outcomes, key performance indicators, designs processes for new initiatives, services and other targets identified by Choctaw Nation Health Services Authority leadership.
4. Serves as an internal consultant to Administration, physicians, and staff in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.
5. Focus on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
6. Coordinate, manage and report Core Measures, MACRA and meaningful use measures and other quality metrics as assigned.
7. Collect and report HCAHPS data for the facility.
8. Organize all Quality Management meetings, maintain minutes and make recommendations to the committee based on best practice and current regulatory standards.
9. Conduct internal audits and risk analysis as determined by the Quality Management Committee.
10. Perform other responsibilities as may be assigned.

• Bachelor’s degree in health or business-related field
• Certified Professional Healthcare Quality (CPHQ), or willingness to obtain
• Knowledge of state and national initiatives related to patient safety and evidenced based guidelines of care
• Knowledge of current trends in scoring regarding JC accreditation and CMS validation surveys
• Experience with data analysis and identification of trends
• Experience in process improvement modalities such as PDCA and Six Sigma
• Six [6] years of experience in quality management and data analysis