Quality Assurance - Manager of Quality and Risk FT​/Day

• Location 300 Canal Street,King City, CA, 93930,United States
• Base Pay $ - $ / Year
• Job Category Management
• Employee Type Full-Time Regular
• Required Degree 4 Year Degree
• Manage Others Yes

The Manager, Quality & Risk leads day-to-day quality improvement, patient/resident safety, risk-management, and regulatory-readiness activities across the organization. This position translates organizational priorities into measurable improvement work, oversees quality and risk staff, and partners with clinical and operational leaders to reduce harm, strengthen compliance, and sustain survey readiness. The role supports a CAH-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program, as required under the CAH Conditions of Participation, and coordinates quality activities across hospital, SNF, and clinic settings.

The duties listed below are the essential functions of this position. Employees must be able to perform these essential functions, with or without reasonable accommodation. This list is intended to describe the primary responsibilities of the position and is not intended to be an exhaustive list of all duties. Additional job-related duties may be assigned as needed.

• Coordinate implementation, maintenance, and evaluation of the organization-wide QAPI program for acute care, emergency services, swing-bed services, the distinct-part SNF, and RHCs.
• Facilitate development of annual quality plans, departmental dashboards, performance-improvement projects, corrective-action plans, and sustainability monitoring.
• Collect, validate, trend, analyze, and present quality, safety, utilization, infection-prevention, patient-experience, and regulatory data.
• Partner with leaders to select meaningful measures based on high-risk, high-volume, problem-prone, and mission-critical services.
• Apply structured improvement methods, such as Plan-Do-Check-Act, root-cause analysis, failure-mode analysis, and process mapping.
• Prepare concise reports, scorecards, and recommendations for Quality Committee, Medical Staff, Infection Prevention, Safety Committee, SNF Quality Assurance/Performance Improvement Committee, Compliance Committee, and Governing Board review.
• Track action items, responsible owners, target dates, outcomes, and effectiveness of corrective actions.

• Oversee the intake, review, investigation, trending, and follow-up of patient, resident, visitor, employee, and facility events, including near misses, complaints, grievances, adverse events, and potentially reportable incidents.
• Facilitate or support root-cause analyses and serious-event reviews; ensure timely documentation, corrective actions, leadership escalation, and follow-up monitoring.
• Identify system vulnerabilities and collaborate with clinical, operational, medical-staff, and human-resources leaders to mitigate risk.
• Maintain incident-reporting standards and educate staff on just culture, event reporting, disclosure processes, and safety escalation pathways.
• Support claims, subpoenas, record requests, liability matters, and insurer/risk-pool communications in coordination with the Director and organizational leadership.
• Assist with maintenance of risk registers, loss-prevention initiatives, safety rounds, environmental rounds, and emergency-management after-action improvement plans.

• Maintain ongoing readiness for CMS, California Department of Public Health, California Title 22, accrediting-bodies (TJC, TCT), and other applicable regulatory surveys.
• Conduct and coordinate tracers, mock surveys, document reviews, focused audits, and rounds across the hospital, SNF, and RHC locations.
• Collaborate with department leaders to develop plans of correction and evidence of compliance; monitor completion and validate sustained implementation.
• Support survey preparation, on-site survey coordination, document production, staff coaching, and post-survey corrective-action follow-up.
• Monitor regulatory and accreditation updates and recommend policy, process, education, or documentation changes to the Director.

• Coordinate quality, resident-safety, grievance, and performance-improvement activities for the distinct-part SNF in collaboration with the SNF Administrator, Director of Nursing, Medical Director, and interdisciplinary team.
• Support SNF quality-assurance activities, including required…