Clinical Quality Assurance & Improvement Specialist

Quality and Compliance Team

Damien Center Values

Dignity-Collaboration-Accountability-Equity-Quality-Innovation

Founded in 1987, Damien Center is Indiana's oldest and largest AIDS service organization (ASO) and serves more than 8000 individuals living with or at risk for HIV through a comprehensive, innovative approach to care and prevention. Our purpose is to be a trusted partner in providing services, education and advocacy for all people living with or at risk for HIV and any person seeking a safe and welcoming home for care. Our services include care coordination, clinical and pharmacy services, mental health, housing, and nutrition.

Position Summary:

The Clinical Quality Assurance and Improvement Specialist (CQAIS), an integral member of the Quality and Compliance team, is responsible for leading the development and implementation of clinical quality assurance and improvement processes. This role, reporting directly to the Quality Manager (QM), applies continuous improvement methodologies to enhance efficiency and effectiveness in clinical quality management. The CQAIS plays a pivotal role in strategic quality planning by contributing to the Clinical Quality Management Plan (CQMP) and the agency-wide Quality Improvement Plan, aligning clinical quality assurance and improvement initiatives with organizational goals.

The position requires a strong commitment to data-driven quality assurance and improvement, utilizing advanced data analysis skills to monitor and enhance clinical quality indicators. The CQAIS collaborates closely with the Health Information Technology (HIT) team and the Data Quality Analyst (DQA) to ensure proper use of data systems for data collection and reporting of clinical quality measures to funders and stakeholders. In fostering a continuous improvement culture, the CQAIS identifies, and addresses weaknesses in clinical services, and engages with clinical teams to highlight quality outcomes. The CQAIS must utilize an agile approach in their ability to undertake special assignments with flexibility to support the overarching goals of the Quality and Compliance team in alignment with the priorities of Damien Center.

Duties and Responsibilities:

This job description describes the general nature and level of work performed by employees assigned to this position. It should not be construed as an exhaustive list of all required duties, responsibilities, and skills.

• Manage the development, implementation, and optimization of robust clinical quality assurance and improvement, ensuring alignment with industry best practices and regulatory requirements, employing continuous improvement methodologies to enhance the efficiency and effectiveness.
• Collaborate with the Chief Clinical Officer (CCO) to review and update the Clinical Quality Management Plan (CQMP), under the direction of the Quality Manager, focusing on improving patient outcomes clinical compliance.
• Acts as a Client Grievance Liaison for the clinic. Annually review grievance process for ease of access to the client, fairness, and timeliness as well as State and Federal requirements.
• Demonstrates commitment to a strategic and data-driven approach to quality management, quality assurance, and continuous improvement in collaboration with key stakeholders.
• Create clinic-related metrics, ensuring that quality clinical outcomes are determined and collected for each clinical program that are measurable and reportable for agency-wide plans such as the Strategic Plan, Diversity, Equity, and Inclusion (DEI) Plan, Clinical Quality Management Plan (CQMP), and Quality Improvement Plan; update these plans with accurate data on a regular basis, as needed.
• Collaborate with the Quality Manager (QM) and the CCO to strategically align clinical quality initiatives with organizational goals and industry standards, including standards and requirements related to Federally Qualified Health Centers (FQHCs) and HIV/AIDS Services Organizations.
• Utilize advanced data analysis skills to monitor and enhance clinical quality indicators and identify opportunities for quality improvement through comprehensive data analysis, leveraging data from Electronic Medical Records (EMR) and other internal and external databases and systems.
• Utilize a proactive, data driven approach to identify and address weaknesses in clinical services through ongoing evaluation and implementation of evidence-based practices, always with a focus of fostering a culture of learning and continuous professional development within the clinical services team, staying abreast of industry trends and best practices.
• Assesses and evaluates client needs and client satisfaction with clinical programs and services through surveys, focus groups, or appropriate methods and develop a plan of action based on the results.
• Acts as an intermediary between the Quality and Compliance team and the HIT team for EMR data reporting activities, requiring a strong knowledge of how the EMR collects and reports data.
• Work in tandem with the Quality and Compliance team to align clinical quality strategies with broader organizational data analysis goals and ensure clinical data complies with local, state, and/or federal requirements by assisting with monthly and quarterly internal audits.
• Compiles, interprets, and reports all clinical quality management data in computerized software, collaborating with the HIT team as needed, to assure accurate and complete quantitative analysis of clinical data and presentation of data analysis results.
• Stay updated on industry trends and best practices in clinical quality assurance and improvement.
• Serve as the Risk Manager for clinical operations, overseeing risk management activities and ensuring compliance with quality indicators and compliance measures.
• Provide practical training and education to clinical staff on quality and compliance measures, including documentation, with a focus on clear, easily understandable materials and presentations.
• Maintain strong confidentiality standards and adherence to HIPAA compliance.
  • Performs special assignments and other work, on an as-needed basis. 

Education and/or Experience

Bachelor's degree in healthcare management, public health, business administration, medical informatics, epidemiology, data science or a similar field related with a focus in healthcare is required. Master's Degree preferred.

Three years of progressive experience in quality management, assurance, and improvement in a clinical setting required, with five or more years preferred. Previous experience working in the nonprofit sector or medical setting required.

Proficiency with survey/evaluation platforms, data systems used in healthcare/medical settings, including electronic medical/health records (EMRs/EHRs), and SAS, SPSS, or other statistical software required. Experience with SQL, Power BI, or other programming or data visualization software is preferred. Certification or documented training in Six Sigma or Continuous Quality Improvement is preferred. Experience in grant reporting and compliance is preferred.

Bilingual in Spanish/English is a plus.

*Work or lived experience may substitute for education requirements on a case-by-case basis.

Knowledge, Skills, and Abilities:

Possess superior organizational and administrative skills. Excellent interpersonal and communication abilities. Excellent computer skills in a Microsoft Windows environment. Ability to work independently and achieve high standards of productivity, achieving deadlines and with superior product results. Strong calendaring, organizational, and document management skills required. Proactive approach to solving problems and communicating to leadership. Knowledge of office management systems, procedures, and office equipment required. Excellent time management skills and ability to prioritize work.

Qualifications

To perform this job successfully, an individual must be able to perform each essential job function satisfactorily. The requirements listed are representative of the basic knowledge, skills, and/or abilities required. Reasonable accommodation may be made for individuals with disabilities to perform the essential functions. The individual in this role must display the highest level of integrity and confidentiality. The individual should have effective communication skills, attention to detail and organization, and flexibility and adaptability. The individual will also maintain knowledge of trends in their area of responsibility.

Physical Demands: 

The physical demands described here are general representations of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made for individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to sit, reach with hands and arms, talk, and hear. The employee frequently is required to use hands to touch and handle objects. The employee frequently stands or walks.
• The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment: 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made for individuals with disabilities to perform the essential functions. Remote work is on a case-by-case basis and must be approved by the supervisor.

• Office setting, with sustained use of a computer.
• The noise level in the work environment is minimal to moderate.
• Individuals should maintain personal and professional competency and work to create an environment of courtesy, respect, inclusion, and positivity in all interactions both internal and external to the organization.

• FLSA Status: Salaried, Full-time, Exempt
• Leader: Quality Manager
• Salary: $65,070 annually

• Benefits: 
• 150 hours of PTO in the first year followed by 195 hours per year moving forward.

• 12 paid holidays
•  Medical coverage options include a PPO plan or a HDHP.
• Dental & Vision plans
• Health Saving Account or Flexible Spending Account
• Dependent Care Flexible Spending Account
• Employee Assistance Program
• 403b Retirement Account with 5% matching and 100% vesting after 90 days
• Life Insurance @ 2 times the annual salary
• Voluntary Life Insurance Plan including spouse and child coverage options
• Short- & Long-Term Disability Plans
• Premium Subscription to the CALM APP which assists with anxiety, stress & other mental health challenges
• Professional Development Opportunities
• Tuition Assistance
• Annual performance review that includes an annual performance-based salary increase

Protecting our team members, clients, volunteers, and community partners is an integral part of how we ensure our continued work with the clients we serve. As a condition of employment, Damien Center requires team members to be vaccinated against influenza and receive a tuberculosis skin test (or chest x-ray) annually, and to be vaccinated against COVID-19 (including all boosters), barring an approved religious or medical exemption.

Damien Center is an Equal Opportunity Employer

Damien Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, family status, ethnicity, national origin, age, disability, marital status, amnesty, status as a covered veteran, other legally protected status, or genetic (including family medical history) information.

Damien Center complies with applicable federal laws and with all state and local laws governing non-discrimination in employment in every location in which Damien Center has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Please apply at www.damien.org/job-opportunities

This position description does not constitute a contract of employment or guarantee of any terms or conditions of employment. Damien Center employees are employed on an at-will basis. Nothing in this position description restricts Damien Center's right to assign or reassign duties and responsibilities to this position at any time.