Nurse Manager, Clinical Integrity and Quality

The Nurse Manager, Clinical Integrity and Quality is responsible for leading quality control and clinical compliance initiatives across CommUnityCare. This role supports organizational readiness for regulatory reviews, ensures adherence to Joint Commission and PCMH standards, advancing clinical quality, documentation accuracy, and regulatory compliance across ambulatory care services. This position supports the organization's goals related to value-based care, patient safety, and population health by ensuring that care delivery aligns with evidence-based guidelines. Promotes a safety culture and infrastructure by engaging stakeholders to understand all perspectives when addressing patient safety issues, model behaviors, educate staff, support adoption of high reliability principles, supports designs of sustainable actions to improve patient care and services.

Essential Functions

Quality Audits and Compliance

• Conduct regular and targeted chart audits to ensure adherence to clinical guidelines, documentation standards, and payer requirements.
• Lead clinical quality control programs to ensure alignment with The Joint Commission, HRSA, PCMH, and internal standards of care.
• Evaluate care delivery against HEDIS and UDS measures, including immunizations, screenings, and chronic disease management.
• Assist in preparing and coordinating external site visits and accreditation surveys.
• Identify documentation gaps or patterns of concern and provide recommendations to address them.
• Maintain up-to-date knowledge of HRSA, Medicaid Managed Care, and other regulatory quality expectations.
• Review and assess clinical documentation, care delivery processes, and interdisciplinary workflows for accuracy, completeness, and integrity.
• Ensure compliance with state, federal, and ambulatory care specific regulations, guidelines, and accreditation standards.
• Maintain accurate records of quality reviews, audits, and corrective actions.
  
  
  

Risk Identification and Mitigation

• Monitor clinical data and patient outcomes to identify high-risk areas (e.g., uncontrolled diabetes, readmissions, missed screenings).
• Work with site leadership to develop, implement, and monitor corrective action plans.
• Responsible for the collection and analyze data to report identified trends, areas for improvement, and potential risks.
• Assist in the investigation of patient complaints, incidents, and adverse events, conducting root cause analysis and implementing corrective actions.
  
  
  

Value-Based Care Support

• Assist in the implementation of care initiatives aligned with value-based payment models (e.g., TCM, CCM, PCMH).
• Provide input on workflows that improve performance in payer quality incentive programs.
• Support clinical teams in closing care gaps and improving patient engagement and outcomes.
• Develop and implement quality dashboards, indicators, and scorecards to drive improvement and accountability.
  
  
  

Education and Training

• Deliver audit feedback and education to providers, nurses, and medical assistants to improve documentation accuracy and clinical care.
• Develop training materials and conduct sessions on compliance, HEDIS/UDS reporting standards and integrity.
• Provide training to staff on quality control processes and best practices.
  
  
  

Collaboration and Reporting

• Collaborate with QI teams, clinical directors, care coordinators, and health IT to ensure seamless quality data collection and use.
• Serve as the nursing liaison in interdisciplinary quality teams, providing clinical oversight and guidance on performance improvement.
• Support the implementation of quality improvement initiatives, clinical pathways, and process redesign.
• Review and assess clinical documentation, care delivery processes, and interdisciplinary workflows for accuracy, completeness, and integrity.
• Analyze data and compile reports on quality indicators, trends, and performance metrics to identify areas for improvement and present summary reports for committee structures.
• Support the creation and implement quality control guidelines, policies, and procedures.
• Collaborate with other healthcare professionals, including physicians, administrators, and other nurses, to address concerns, implement changes, and improve patient outcomes.
  
  
  

Knowledge, Skills and Abilities

• Expert knowledge of clinical quality standards, nursing protocols, and healthcare regulatory frameworks.
• Skilled in data analysis, audit tools, and performance reporting.
• Strong project management, facilitation, and communication skills.
• Proficient in EHR systems, quality software, and documentation review tools.
• Ability to influence and collaborate across clinical and administrative teams.
  
  
  

Work Experience

5 years of nursing and clinical leadership required

Licenses and Certifications

Active RN License in the State of Texas

Certified Professional in Healthcare Quality (CPHQ) required or must be obtained with 18 months of holding the position, or equivalent