Manager of Clinical Quality & Performance

The Manager of Clinical Quality & Performance is responsible for the operational leadership and daily management of the Continuous Improvement Department. This role oversees the implementation of clinical quality initiatives, workflow improvement efforts, care gap closure strategies, quality reporting activities, and departmental operations across Sandhills Medical Foundation.

This position serves as the primary operational leader for the Continuous Improvement Department, translating organizational quality, compliance, performance, and regulatory strategies established by the VP of Organizational Performance, Compliance & Continuous Improvement into actionable workflows, staff accountability, measurable outcomes, and departmental execution plans.

The Manager directly oversees the Continuous Improvement Analyst and Clinical Continuous Improvement Specialist while supporting the implementation and monitoring of quality improvement activities throughout the organization.

Essential Duties & Responsibilities

Department Operations & Staff Leadership

• Provide day-to-day operational oversight of the Continuous Improvement Department.
• Directly supervise:
  • Continuous Improvement Analyst
  • Clinical Continuous Improvement Specialist
• Indirectly oversee Continuous Improvement Navigators.
• Monitor staff productivity, accountability, project completion, and performance outcomes.
• Conduct performance evaluations and establish individual development plans.
• Assist with onboarding, training, coaching, and professional development activities.
• Support departmental workflow standardization and process improvement.
• Develop and maintain departmental work plans, project timelines, and accountability structures.

Clinical Quality & Performance Management

• Oversee implementation of Continuous Quality Improvement (CQI) initiatives across all clinical service lines.
• Monitor organizational performance related to:
  • UDS measures
  • Preventive screenings
  • Chronic disease management
  • Access initiatives
  • Value-based care performance
  • Care gap closure
  • Population health initiatives
• Assist with development and execution of corrective action plans and performance improvement initiatives.
• Monitor provider, care team, and site-level quality performance trends.
• Coordinate interventions designed to improve clinical outcomes and operational performance.
• Support achievement of organizational quality goals and strategic initiatives.

Operational Workflow Improvement

• Lead workflow redesign initiatives focused on:
  • Access improvement
  • No-show reduction
  • Care coordination
  • Throughput improvement
  • Documentation optimization
  • Patient engagement
• Collaborate with operations, nursing, providers, and support staff to improve efficiency and patient outcomes.
• Evaluate workflow effectiveness and recommend process enhancements.
• Support implementation of organizational initiatives and operational changes.
• Assist departments with identifying barriers to performance and implementing sustainable solutions.

Reporting & Data Oversight

• Review and validate quality reports, dashboards, scorecards, and performance metrics.
• Ensure data accuracy and integrity related to quality reporting activities.
• Assist with executive, Board, Quality Committee, and operational reporting preparation.
• Monitor departmental project tracking and performance accountability tools.
• Partner with the Continuous Improvement Analyst to identify trends, opportunities, and areas requiring intervention.
• Utilize data to drive operational decision-making and performance improvement efforts.

Regulatory & Quality Program Support

• Support operational readiness activities related to:
  • HRSA
  • UDS
  • PCMH
  • Operational Site Visits (OSV)
  • Value-based care programs
  • Quality audits
  • Accreditation and regulatory initiatives
• Assist with audit preparation, evidence collection, workflow implementation, and corrective action monitoring.
• Collaborate with the VP regarding compliance-related initiatives and organizational priorities.
• Support development and maintenance of policies, procedures, and documentation standards related to quality and performance improvement activities.

Cross-Functional Collaboration

• Work collaboratively with:
  • Clinical Leadership
  • Operations
  • Nursing
  • Behavioral Health
  • Pharmacy
  • IT/EHR Teams
  • Registration
  • Referral Teams
  • Executive Leadership
• Participate in quality committees, operational meetings, and organizational improvement initiatives.
• Serve as a resource for quality improvement and performance management activities.
• Promote a culture of accountability, quality improvement, collaboration, and patient-centered care throughout the organization.

Qualifications

Education

• Bachelor's degree in Healthcare Administration, Nursing, Public Health, Healthcare Quality, Business Administration, or related field preferred.
• Master's degree preferred.
• Equivalent healthcare leadership experience may be considered.

Experience

• Five (5) or more years of healthcare quality, clinical operations, population health, performance improvement, or healthcare management experience required.
• Federally Qualified Health Center (FQHC) experience strongly preferred.
• Experience supervising staff and leading operational initiatives required.
• Experience with:
  • UDS reporting
  • HRSA Health Center Program requirements
  • PCMH recognition standards
  • Quality reporting and analytics
  • Workflow redesign
  • Population health management
  • Value-based care programs
  • Regulatory readiness activities

Knowledge, Skills & Abilities

• Strong operational leadership and organizational skills.
• Knowledge of healthcare quality measures, quality improvement methodologies, and regulatory requirements.
• Ability to manage multiple projects and competing priorities in a fast-paced environment.
• Strong analytical and problem-solving abilities.
• Excellent communication, facilitation, and leadership skills.
• Ability to translate strategy into operational execution.
• Strong understanding of EHR workflows, reporting systems, population health tools, and quality performance monitoring.
• Ability to build collaborative relationships across departments and levels of leadership.
• Strong project management and accountability management skills.