Quality Improvement ​/ Quality Assurance ​/ Compliance Registered Nurse (QI​/QA RN

Quality Improvement / Quality Assurance / Compliance Registered Nurse (QI/QA/Compliance RN)

The Quality Improvement / Quality Assurance / Compliance Registered Nurse (QI/QA/Compliance RN) is responsible for leading and supporting the health center's quality improvement, patient safety, risk management, and regulatory compliance programs. This position ensures compliance with HRSA Health Center Program Requirements, Federal Tort Claims Act (FTCA) standards, Uniform Data System (UDS) reporting requirements, and applicable Federal, State of Alaska regulations.

The QI/QA/Compliance RN works collaboratively with clinical leadership, providers, nursing staff, and administrative teams to promote continuous performance improvement, patient safety, and high-quality, culturally responsive care in Alaska's rural, frontier, and remote healthcare environments.

Quality Improvement (QI)

• Lead and coordinate the organization-wide Quality Improvement (QI) Program
• Facilitate Plan‑Do‑Study‑Act (PDSA) cycles and performance improvement initiatives
• Monitor, analyze, and trend Clinical Quality Measures (CQMs), including UDS clinical measures
• Identify gaps in care and work with clinical teams to implement and sustain improvement strategies
• Support value‑based care, patient‑centered medical home (PCMH), and care integration initiatives
• Incorporate health equity principles into quality improvement activities

Quality Assurance (QA)

• Conduct routine and targeted clinical chart audits to assess quality of care and documentation
• Monitor compliance with evidence‑based guidelines, clinical protocols, and standing orders
• Participate in peer review and clinical case review activities
• Identify quality concerns and ensure corrective actions are implemented and monitored
• Track trends related to clinical outcomes and quality indicators

Compliance & Regulatory Oversight

• Ensure ongoing compliance with: HRSA Health Center Program Requirements, including the HRSA Operational Site Visit (OSV);
  Federal Tort Claims Act (FTCA); CMS and Medicaid requirements;
  Alaska Board of Nursing and state regulations; HIPAA, OSHA, and CLIA (as applicable)
• Maintain readiness for audits, surveys, and regulatory reviews, including the HRSA Operational Site Visit (OSV)
• Assist with policy development, review, and revision to ensure regulatory alignment
• Maintain compliance documentation and tracking tools

FTCA Risk Management & Reporting

• Coordinate the health center's FTCA Risk Management and Claims Prevention Program
• Support the annual FTCA Deeming Application
• Track, review, and trend: incident reports; patient complaints and grievances; adverse events and near misses
• Conduct or support root cause analyses (RCAs) and corrective action plans
• Coordinate follow‑up actions and monitor risk mitigation strategies
• Maintain required FTCA documentation and reporting records
• Collaborate with leadership and legal counsel as appropriate

Uniform Data System (UDS) Reporting

• Support and coordinate UDS reporting and data validation
• Validate clinical quality measure accuracy through chart audits and data review
• Collaborate with providers, nursing, IT, billing, and data teams to ensure data integrity
• Analyze UDS data to identify trends, gaps, and opportunities for improvement
• Use UDS results to inform quality improvement initiatives
• Support timely submission of UDS data in accordance with HRSA requirements

HRSA Operational Site Visit (OSV) Compliance & Reporting

• Ensure continuous compliance with HRSA Health Center Program Requirements
• Coordinate preparation for HRSA Operational Site Visits (OSVs), including: evidence collection and organization; policy and procedure review; staff education and readiness
• Conduct or participate in mock site visits as needed
• Track OSV findings and coordinate Corrective Action Plans (CAPs)
• Support post‑OSV reporting and ongoing HRSA communications
• Promote continuous compliance rather than event‑based preparation

Infection Prevention & Patient Safety

• Coordinate and support the Infection Prevention and Control Program
• Monitor compliance with CDC, HRSA, OSHA, and Alaska public health guidance
• Conduct infection control audits and staff education
• Support…