RN Quality Improvement & Metrics Manager

DescriptionPOSITION SUMMARY:

The RN Quality Improvement & Metrics Manager is responsible for leading the organization’s quality improvement, performance measurement, regulatory compliance, and population health initiatives. This role partners with clinical and operational leaders to improve patient outcomes, enhance access to care, optimize value-based reimbursement, and ensure compliance with Health Resources and Services Administration (HRSA) requirements and other regulatory standards.

The successful candidate will use clinical expertise, data analysis, evidence-based practice, and performance improvement methodologies to strengthen organizational quality programs and support the mission of providing high-quality, patient-centered care to medically underserved communities.

Mission Alignment

The RN Quality Improvement & Metrics Manager is committed to advancing the mission of the health center by improving access, quality, equity, and patient outcomes for the communities we serve. This position promotes a culture of continuous improvement and supports the organization’s commitment to delivering high-quality, affordable, and patient-centered primary care.

This version is aligned with HRSA expectations and reflects the responsibilities typically expected of an FQHC quality leader. It can also be further customized if your health center participates in specific programs such as Accountable Care Organizations (ACOs), Medicare Shared Savings Program (MSSP), or state Medicaid value-based payment initiatives.

ESSENTIAL FUNCTIONS:

Quality Improvement

Develop, implement, and evaluate organization-wide quality improvement initiatives.
Lead Performance Improvement (PI) projects using evidence-based methodologies.
Facilitate Plan-Do-Study-Act (PDSA) cycles and other quality improvement strategies.
In collaboration with the CMO, provide education and regular feedback related to quality metrics and provider performance.
Monitor outcomes and recommend system improvements that enhance patient care and operational efficiency.
Collaborate with HIPAA Compliance Manager to prepare board reports and meeting agendas

Quality Metrics & Performance Monitoring

Lead monitoring and reporting of key performance measures and others as defined by HRSA health standards:

Clinical Quality Measures (CQMs)
Preventive health screenings
Chronic disease management outcomes
Diabetes control
Hypertension control
Childhood and adult immunization rates
Women’s preventive health measures
Population health outcomes
Develop dashboards and scorecards that communicate organizational performance to providers, leadership, and governing boards.
Serve as a resource for evidence-based practice and clinical quality initiatives.

Regulatory Compliance

Ensure compliance with:

HRSA Health Center Program requirements
Uniform Data System (UDS) reporting
CMS quality reporting programs
HIPAA regulations
OSHA standards
State Department of Health regulations
Patient-Centered Medical Home (PCMH) standards, when applicable
Federal and state quality initiatives
Coordinate preparation for HRSA Operational Site Visits (OSVs), accreditation surveys, and external audits.

Population Health Management

Collaborate with clinical teams to improve health outcomes for high-risk and vulnerable patient populations by:

Identifying care gaps
Monitoring chronic disease registries
Improving preventive care compliance
Supporting care management initiatives
Evaluating social determinants of health data
Developing interventions that improve health equity

Data Analysis & Reporting

Analyze clinical, financial, and operational data to identify trends and opportunities for improvement.
Create meaningful dashboards using electronic health record data.
Present findings to executive leadership, Chief Medical Officer, Providers, and RN Administrator
Monitor provider quality performance and recommend improvement strategies.
Ensure accuracy of quality reporting submitted to HRSA and other regulatory agencies.

Education

Educate providers and staff on quality measures and performance expectations.
Develop training related to quality initiatives, clinical guidelines, and regulatory requirements.

Promote a culture of continuous quality improvement throughout the organization
QualificationsPOSITION REQUIREMENTS:

Education/Experience

Bachelor of Science in Nursing (BSN) required
Master’s degree in nursing, Public Health, Healthcare Administration, or related field preferred

Licensure

Current unrestricted Registered Nurse (RN) license

Skills/Abilities

Minimum five (5) years of nursing experience
Minimum three (3) years of experience in quality improvement, clinical quality, population health, regulatory compliance, or performance improvement
Experience within a Federally Qualified Health Center, community health center, primary care organization, or ambulatory care setting preferred
Experience with Value Based Care

Preferred Certifications

Certified Professional in Healthcare Quality (CPHQ)

Knowledge, Skills, and Abilities

Demonstrated knowledge of:
HRSA Health Center Program requirements
Uniform Data System (UDS)
Clinical Quality Measures (CQMs)
HEDIS
Value-Based Care
Population Health Management
Care Gap Closure
Chronic Disease Management
Evidence-Based Practice
Quality Improvement methodologies
Regulatory Compliance
Patient-Centered Medical Home (PCMH)
Health Equity initiatives
Social Determinants of Health (SDOH)

Ability to:

Interpret complex clinical data
Lead interdisciplinary quality initiatives
Develop executive-level reports and dashboards
Manage multiple priorities simultaneously
Communicate effectively with providers, leadership, and external stakeholders
Build collaborative relationships across departments

Technical Skills

Experience with:

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