RN Quality Improvement/Compliance Manager

  • Rifle, CO
  • Full-time

Company Description

Mountain Family Health Centers (MFHC) are in Glenwood Springs, Basalt, Rifle and Black Hawk Colorado. Each community health center is as unique as the town in which it is located, but all share the same mission:

“To provide high quality, integrated primary, behavioral, and dental health care in the communities we serve, with special consideration for the medically underserved, regardless of ability to pay.

Job Description


The Quality Improvement (QI) Supervisor at the direction of the Medical Director of Integrated Care is responsible for the ongoing development of quality improvement strategies, growth and oversight/authority of all QI projects in collaboration with respective team members. They are responsible for tracking and managing QI through data analytics, high standards of care management practice, development of policies, protocols and practice guidelines, participating in rigorous performance improvement monitoring, and staff education. This position participates in clinical and administrative decision-making with special attention paid to the pursuit of the IHI Triple Aim of improved patient outcomes, enhanced population health and controlling cost.  Utilize the transparent QI process for review and improvement of adverse events and/or poor outcomes.                                                                       


ESSENTIAL DUTIES/RESPONSIBILITIES (Listed in descending order of importance)

A.  Quality Improvement

  1. Regularly meet with site supervisors/provider champions to review reports and support goals toward achieving Triple Aim
  2. Manage and mentor quality improvement support staff to facilitate ongoing site continuous quality improvement  
  3. Coordinate review and update of policies and procedures ensuring annual review and/or revision including the annual quality improvement plan.
  4. Facilitate Quality Improvement Team meetings and Board Reports
  5. Oversee reapplication/attestation process for PCMH recognition
  6. Compile necessary documents for HRSA site visits, HRSA/grant applications, UDS report submission
  7. Compile peer review documents are requested for routine and non-routine peer review processes.
  8. Collaborate with nurse operations manager to ensure record reviews of clinical support work and identify opportunities for education
  9. Collaborate with human resources to ensure availability and integration of staff training in whole-person care
  10. Compile and schedule chronic disease/preventive health registry management reports
  11. Update, compile clinical performance measures that we make public
  12. Update,distribute, and report semi-annually on patient experience surveys
  13. Provide new employee orientation and introduction to quality activities


B.  Supervisory Duties:

  1. Hires and evaluates staff, mediates disputes within and between sites.
  2. Works closely with the Medical Director of Integrated care, and Nurse Operations Manager to meet and or exceed the stated goals of MFHC’s yearly quality improvement plan. .
  3. Mentors, guides and coaches direct reports in order to expand their capabilities and build depth in the department of care coordination.
  4. Provides guidance/support and meets with employees as needed.
  5. At direction of Medical Director of Integrated Care, responsible for approving all reviews and/or formal disciplinary action including termination and ensures compliance with MFHC policies.


C.  Communication/Interpersonal:

  1. Communicate effectively, courteously and collaboratively with patient/family, providers, supervisors and co-workers.
  2. Promotes positive teamwork and cohesiveness between staff members and other health care providers.
  3. Demonstrates ability to establish and maintain effective positive working relationships with patients, families, co-workers and the public.
  4. Respects various differences in communication, i.e. language, culture, gender and family structure.


D.  Data Analytical Duties:

  1. Facilitate management of chronic disease and preventive care registries.
  2. Assist with and/or facilitate record reviews as required by outside agencies/vendors.
  3. Support care management review process through quality review and documentation of utilization via chart audits.
  4. Accurately use data for documentation, tracking and trending.
  5. Maintain on-going communication and feedback with internal and external customer that is timely with the sites and PCP practice teams to identify areas of quality improvement. .
  1. Assist PCP in developing QI plans to improve outcomes, increase patient engagement in self-care..
  1. Develops and supports effective partnerships within the community to better meet QI needs.


E.  Service Excellence

  1. Maintain a positive, helpful attitude to patients/family, providers and co-workers.
  2. Demonstrate an awareness of and commitment to the common goal of providing excellent patient care.
  3. Participate in and support care coordination team meetings and activities.


F.  Professionalism

  1. Sick time does not exceed MFHC policy parameters.
  2. Follow through on assignments to completion.
  3. Utilize appropriate chain of command.
  4. Does not allow social interaction to interfere with health center workload.
  5. Consistently demonstrate strict adherence to policies and procedures concerning patient/ confidentiality and release of information.
  6. Consistently report to work on date and time scheduled without incurring tardiness.
  7. Take and return from scheduled breaks and meal breaks in a timely manner.
  8. Maintain a professional appearance and good hygiene.


G.  Leadership

  1. Promotes teamwork as demonstrated by support for each other, the patient/family, team and community resources.
  2. Coordinates cooperatively with the treatment team and community resources for productive problem solving and high quality patient care.
  3. Acts as a resource, communicating appropriate knowledge, skills and conduct.
  4. Shares expertise and collaborates with all health center staff at every level in a positive and compassionate manner.


H.  Safety/Risk Management

  1. Adhere to health center safety, infection control and hazardous waste procedures.
  2. Identifies patient situations indicative of high clinical, financial and/or liability risk

 I.    General Employee Responsibilities

  1. Participate in Quality Improvement processes and activities in the organization.
  2. Embrace the mission, vision and values of the Board of Directors of Mountain Family Health Centers.
  3. Maintain patient confidentiality at all times in accordance with HIPAA regulations.
  4. Competent and appropriate use of electronic media for communication within the health center:  electronic health record, electronic practice management software, e-mail and IM.



  1. Education or Formal Training & Experience: 
    1. Two  (2) years’ experience in quality improvement and management.   .
    2. Demonstrate excellent communication, assessment and problem solving skills.
    3. Competent and proficient in computer skills and EHR/EPM use.
    4. Bi-lingual in English/Spanish preferred.



  1. Knowledge, Skill & Ability: (include materials and equipment directly used)
    1. Ability to organize and prioritize work load.
    2. Maintain effective and positive professional working relationship with staff and patients.
    3. Ability to understand and respond effectively and with sensitivity to special populations served by MFHC.
    4. Ability to work under pressure in a fast-paced environment.
    5. Ability to travel to other locations and to meetings outside of the service area.
    6. Ability to work flexible hours to meet job requirements.



  1. Physical Requirements and Workplace Environment:
    1. Requires ability to lift, carry, push and pull up to 35 pounds.
    2. Requires ability to use routine office equipment such as computer and telephone.
    3. Requires ability to stoop, kneel, bend, crouch and reach.
    4. Requires sufficient near-vision to be able to read documents and computer screen.
    5. Requires ability to comprehend both oral and written communications.
    6. O.S.H.A. Category 1:  All procedures or other job-related tasks involve an inherent potential for mucous membrane or skin contact with blood, body fluids or tissues or a potential for spills or splashes of these fluids.
    7. HIPAA Classification:  Unrestricted Access: A workforce member with unrestricted access will have full access to patient’s protected health information, including the patient’s entire medical record, for patient care purposes.