Quality Management and Improvement Manager

Position Summary

The Quality Management & Improvement Program Manager provides leadership, coordination, and oversight of the organization's Quality Management and Improvement (QM&I) Program. This role ensures compliance with accreditation and regulatory standards, including AAAHC, NCQA, HRSA, and IHS requirements, while promoting a culture of continuous quality improvement across the organization.

Essential Duties and Responsibilities

Program Leadership & Oversight

• Lead the design, implementation, and ongoing management of the Quality Management and Improvement Program.
• Oversee execution of the Quality Improvement Plan, including development of annual work plans, evaluation of outcomes, and preparation of annual reports to the Board of Directors.
• Coordinate and submit regular quality improvement reports to the Board of Directors and Quality Management & Improvement Committee.
• Lead the coordination and documentation of quality improvement infrastructure across all departments.
• Develop, standardize, monitor and oversee use of quality improvement methodologies, including PDSA frameworks across all departments.
• Ensure all departments maintain active quality improvement initiatives supported by accurate and timely data.
• Provide project management support for clinical quality metrics and improvement workflows.
• Provide education, training, and coaching to staff and leadership on quality improvement principles, accreditation standards, and regulatory requirements.
• Coordinate patient experience survey processes and ensure analysis of trends and opportunities for improvement.
• Support departments in aligning quality improvement initiatives with organizational priorities and regulatory standards.

Accreditation, Compliance & Regulatory Readiness

• Serve as the primary point of contact for accreditation and survey readiness activities by leading and coordinating AAAHC accreditation, NCQA recognition/reporting, HRSA audits, and IHS audits.
• Conduct mock surveys and prepare staff and leadership for on-site reviews.
• Maintain documentation and crosswalks demonstrating compliance with all applicable standards and regulations.

Policy & Documentation Management

• Lead policy development, review, tracking, and compliance oversight.
• Ensure organizational policies and process maps align with AAAHC and NCQA standards.
• Manage the Compliatric Document Management System to support policy lifecycle and compliance tracking.

Collaboration & Data Integration

• Collaborate with Health Information Technology (HIT), Risk Management and clinical leadership to align quality metrics with accreditation and regulatory requirements (e.g., CMS eCQMs, UDS measures).
• Develop and maintain organizational and departmental performance dashboards.
• Coordinate, facilitate, and participate in organizational committees and workgroups, including Quality Improvement & Management, PCMH, Compliance/Policy, Infection Control and Prevention and Safety, and Peer Review.
• Perform other related duties as assigned.

Knowledge, Skills & Abilities

Management & Compliance

• Knowledge of organizational administration, fiscal/personnel management, and applicable local, State of Wisconsin, and federal regulations
• Skilled in qualitative/quantitative, financial, and operational analysis across healthcare systems, business processes, and project management
• Experience with electronic document management and accreditation platforms (e.g., Compliatric, NCQA QPASS, AAAHC 1095 Engage), including uploading and managing supporting documentation.
• Proficient in Microsoft Office (Word, Excel) and information systems
• Demonstrated knowledge of, and at least 5 years of experience with, regulatory and accreditation requirements, including AAAHC, NCQA, IHS, and HRSA standards.

Leadership & Problem Solving

• Proven leadership, team-building, influencing skills and demonstrates cultural competence
• Strong critical thinking, creativity, and complex problem resolution
• Effective communicator with strong interpersonal and customer service skills
• Able to build relationships, work across diverse teams, and drive consensus
• Highly organized, detail-oriented, and reliable; able to prioritize, multi-task, and adapt in dynamic environments

Education & Qualifications

• Minimum required qualification is a Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field.
• Master's degree in Nursing, Healthcare Administration, Public Health, or a related field is preferred.
• Minimum of 3 years of experience in healthcare quality improvement, or a minimum of 10 years of experience in healthcare administration or clinical practice.
• Proven experience with standardized clinical quality measures, data analytics, AAAHC quality improvement studies, Plan-Do-Study-Act (PDSA) cycles, and established quality improvement frameworks.
• Clinical experience in a primary care setting is preferred.
• Experience with EPIC OCHIN or other electronic health record (EHR) systems is preferred.

The Gerald L. Ignace Indian Health Center, Inc. provides equal employment opportunities to applicants and employees without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability. Equal Opportunity employer/Veteran/Disabled. American Indian and Veteran Preference employer.