Manager, Performance Improvement-Clinical Quality

Whatever the role, everyone at Grady is part of something bigger. Choosing a career at Grady is choosing to be part of a legacy of service and commitment to our communities. If you want to make a difference, we want to hear from you.

Job Summary

Summary:

The Manager Clinical Performance Improvement (MCPI) provides overall leadership, vision and direction of the Clinical Performance Improvement Department within the Quality Division. This position ensures the appropriate planning, implementation and monitoring of clinical performance improvement activities. The Manager Clinical Performance Improvement works collaboratively with appropriate stakeholders to ensure that all organizational and regulatory agency requirements are met.

Job Responsibilities

• Leads the daily operations of the Clinical Performance Improvement Department and establishes Performance Improvement priorities for the team and in conjunction with other Grady leadership initiatives.
• Manages the completion of the mortality review for the organization.
• Cultivates strong working relationships with Nursing and the Chiefs of Service to ensure quality/performance improvement efforts are identified, resourced, and supported. Directs the service-based performance improvement efforts through focused and generic reviews of services and High Volume (HV), High Risk (HR), Problem Prone (PP), and High Complications (HC) cases.
• Develops, manages and controls budgetary requirements for team success.
• Creates policy and procedures that support Performance Improvement activities.
• Coordinates clinical care standardization through protocols, order sets or process improvement activities.
• Abstracts, submits and identifies performance improvement efforts associated with Centers for Medicare and Medicaid Services (CMS) and the Joint Commission Core Measures (ORYX) as needed.
• Serves as the data resource, in collaboration with the Manager of Clinical Quality Analytics, for clinical performance improvement activities and the distribution, reporting and coordination of activities associated with said improvement efforts.
• Works effectively with other divisions and departments in driving positive quality improvements.
• Demonstrates strong initiative in carrying out assignments and meeting deadlines.
• Promotes open communication, respect, and positive interactions with all levels of staff within the hospital and is a positive role model.

Qualifications:

• Bachelor's Degree in Nursing.
• Master's Degree in Public Health, Hospital Administration, Business Administration or related field preferred.
• 5 years of hospital-based performance improvement, quality assurance, or utilization management experience.
• 3 years of experience in leadership/management role. Experience with chart abstracted quality measures for CMS and TJC required.
• Quality certification.

Core Competencies
These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

1. Patient-Centered Care – Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.
2. Integrity & Accountability – Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
3. Collaboration & Teamwork – Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
4. Communication – Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
5. Respect & Inclusion – Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.
6. Quality & Safety – Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.
7. Adaptability & Resilience – Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.
8. Continuous Improvement – Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.
9. Leadership & Professionalism – Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.
10. Employee Experience Focus – Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.

Grady Total Rewards
At Grady, we believe in supporting the health, well-being, and growth of every team member. Our Total Rewards package is designed to provide competitive pay and comprehensive benefits that make a difference in your life and career, including:

• Health & Wellness: Medical, dental, vision, and prescription drug coverage.

• Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.

• Work-Life Balance: Paid time off, holidays, and family leave benefits.

• Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.

• Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.

Grady’s Total Rewards are designed to ensure our employees feel valued, supported, and empowered, both at work and beyond.

Why Join Grady?
Grady Health System is more than a hospital — we are a vital part of Atlanta and the surrounding communities. For over 125 years, Grady has been committed to providing exceptional care, advancing health equity, and making a difference in the lives of those we serve. When you join Grady, you become part of a team that values excellence, compassion, innovation, and collaboration.

Here, every role matters. Whether you provide direct patient care, support our operations, or lead teams, you play an important part in fulfilling our mission. We offer opportunities to learn, grow, and build a meaningful career in an environment where your contributions are recognized and valued.

At Grady, we don’t just work, we make an impact.

Equal Opportunity Employer Statement:
Grady Health System is proud to be an equal opportunity employer. We are committed to fostering a workforce where all employees feel valued, respected, and empowered to succeed. We prohibit discrimination and harassment of any kind based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.

Grady is dedicated to creating an accessible work environment and provides reasonable accommodations to qualified individuals with disabilities to ensure equitable opportunities for success.