Director Of Clinical Quality Ut Health Rgv

Posting Number: SRGV
9190

Number of Vacancies: 1

Location: Edinburg, Texas

Department: School of Medicine / Ambulatory Operations

FLSA: Exempt

To direct and maintain operational oversight of all clinic(enterprise, hospitals liaison) performance improvement, quality outcomes, risk reduction/mitigation, infection control, patient safety, patient experience, peer review, policy review, and regulatory management operations.

• Directs and maintains operational oversight of all clinic(enterprise, hospitals liaison) performance improvement, quality outcomes, risk reduction/mitigation, infection control, patient safety, patient experience, peer review, policy review, training and development, and regulatory management operations.
• In collaboration with the Associate Dean for Clinical Affairs,establishes where appropriate and supports or leads committeesresponsible for the development of the UT Health RGV clinical performance improvement, quality outcomes, risk reduction/mitigation, infection control, patient safety, patient experience and regulatory management operational annual goals, and reporting.
• Leads quality measurement, reporting, and improvement forvalue-based and pay-for performance arrangements, including
  
  Accountable Care Organizations (ACO/MSSP/ACO REACH), Medicare Advantage (CMS Star Ratings and HEDIS), and CMS quality programs(MIPS/MVPs under the CMS Quality Payment Program,
• Partners with payers any affiliated IPA/ACO on measure performance, care-gap closure, and incentive optimization.
• Leads the design, implementation, and optimization of operational workflows grounded in evidence-based best practices to improve clinical quality performance, enhance operational efficiency, and advance value-based care initiatives across the medical school and health practice.
• Assumes responsibility for communication and education regarding performance improvement, quality outcomes, risk reduction/mitigation, infection control, patient safety, patient experience and regulatory management operations throughout the clinical enterprise.
• Assists the department with development of peer reviews.
  
  Prepares initial on boarding orientation plan and annualcompetencies for purposes of training and development.
• Directs the quality program and serves as Patient Safety Officer for UT Health RGV
• Maintains and monitors current infection control practices.
• Coordinates and directs activities related to selectedaccreditation standards and continuous readiness and ensuesidentified deficiencies are addressed and resolved.
• Develops, promotes and monitors patient satisfactionefforts.
• Follows all current standards and guidelines in the application of performance improvement, quality outcomes, risk reduction/mitigation, infection control, patient safety, patient experience and regulatory management operations.
• Works collaboratively with legal counsel, physicians, staff and executive administration in coordinating and overseeingactivities.
• Collaborates when appropriate with external hospitals andclinic partners in areas of performance improvement, quality outcomes, risk reduction/mitigation, infection control, patient safety, patient experience and regulatory management operations.
• Reviews policies and procedures for regulatory guidelines and standards of care. Works closely with compliance to monitor annual compliance requirements.
• Performs other duties as assigned.

General supervision from assigned supervisor.

Direct supervision of assigned staff.

Bachelor's degree in Nursing or related field from an accredited university.

Master's degree in Nursing or a related field from an accredited university.

Texas Registered Nurse (RN) license in good standing (or amultistate/compact license eligible for practice in Texas).Preferred:
Lean or Six Sigma certification;
Certified Professional in Healthcare Quality (CPHQ).

• Five (5) years of progressive responsible experience in clinical quality, performance improvement, and quality management principles and processes or
• Seven (7) years of the required experience with an Associate'sdegree in Nursing (ADN).
• Demonstrated expertise in quality metrics, performance improvement methodologies, and driving measurable organizational outcomes. Strong working knowledge of value-based care andpay-for-performance programs, including Accountable Care Organizations (ACO's), Medicare Advantage (Star…