Quality Improvement and Accreditation Director

Job Details

Job Location:

Coos Bay, OR 97420

Position Type:
Full Time Education Level: 4 Year Degree Salary Range: $92,705.60 - $ Salary/year

This position is a covered position as defined in the Coquille Indian Tribe Chapter 185 Child Protection Ordinance.

Candidate must pass a pre-employment drug screen and Criminal and Character Background Check.

Under the direct supervision of the Chief Operating Officer, the Quality Improvement and Accreditation Director is responsible for leading, developing, and implementing comprehensive quality improvement, patient safety, and risk management programs. Provides strategic leadership for organizational performance improvement through the development of clinical benchmarking systems, enterprise-wide quality reporting, population health measurement, and cross-departmental improvement initiatives that support integrated, team-based care and advance the health and wellness of Tribal members and communities.

• Provide leadership and oversight for quality improvement, quality assurance, patient safety, and risk management initiatives that improve outcomes for staff, patients, clients, and the Health and Wellness Division. Develop and oversee processes for monitoring and improving quality of care.
• Supervise the Quality Improvement Manager and other assigned staff, providing direction, coaching, performance management, and professional development.
• Design, implement, and evaluate a comprehensive clinical quality measurement and benchmarking program. Collaborate with leadership and clinical teams to establish meaningful quality metrics, monitor performance against internal and external benchmarks, and identify opportunities for improvement.
• Lead the collection, analysis, interpretation, and presentation of clinical and operational performance data to support strategic decision-making, operational efficiency, regulatory compliance, accreditation, and organizational accountability.
• Develop and oversee quality dashboards and scorecards that communicate performance outcomes, benchmark comparisons, trends, and progress toward strategic and operational goals.
• Lead organization-wide performance improvement initiatives using evidence-based methodologies, including PDSA and root cause analysis. Develop corrective action plans and monitor the effectiveness and sustainability of interventions. Partner with medical, dental, behavioral health, pharmacy, rehabilitation, nutrition, community/public health, and other leaders to develop quality improvement and community health initiatives that advance team-based, patient-centered, culturally responsive care and improve health outcomes.
• Collaborate with executive leadership to establish annual quality priorities, organizational performance targets, and department-specific goals aligned with Health and Wellness Division strategic objectives and Tribal health priorities.
• Monitor healthcare disparities, health equity measures, access, utilization, and population health outcomes. Partner with leadership to develop strategies that improve outcomes while honoring Tribal values, traditions, and culturally informed practices.
• Collaborate with information technology, electronic health record teams, and department leaders to improve data integrity, reporting capabilities, and use of clinical information systems to support quality improvement and population health management.
• Promote a culture of continuous quality improvement by providing education, coaching, and technical assistance to leaders, providers, supervisors, and staff regarding quality improvement principles, performance measurement, patient safety, and regulatory requirements.
• Oversee and support the incident review and complaint process for KWC and use findings and trend data to identify opportunities for ongoing quality improvement and risk reduction.
• Oversee and support preparation for regulatory and accreditation reviews, including AAAHC, CARF, and other applicable oversight organizations.
• Educate and assist department supervisors in maintaining policies and procedures that meet regulatory and organizational requirements. Ensure policies and procedures are reviewed regularly and that operational practices are consistent with approved policies.
• Lead Quality Improvement Committee meetings or support an assigned designee and ensure follow-through on committee recommendations and action items.
• Coordinate complex, system-wide projects involving multiple…