Performance Improvement Manager I Quality

The Process Improvement Manager is responsible for leading initiatives that enhance operational efficiency, patient safety, quality of care, and financial performance across the hospital. This role collaborates with leadership, clinical staff, and support departments to identify opportunities for improvement, design and implement process changes, and monitor results to ensure sustainable impact. The Process Improvement Manager uses data-driven analysis, project management, and change management techniques to drive a culture of continuous improvement

Summary of Essential Functions

• Responsible for managing performance improvement activities related to assigned functions (core measure and outcome reporting and internal auditing). 
• Assist with ensuring compliance with all regulatory requirements, planning, monitoring, and evaluation of performance improvement. 
• Manage activities that promote quality outcomes and patient throughput while supporting a balance of optimal care and appropriate resource utilization.
• Leads the Good Catch Program 

• Gathers and analyze health care data and facilitates priority setting to improve clinical outcomes, lower the cost of care, and improve patient and provider experience.

• Coordinate the implementation of the action plans from RCAs.

• Establish a monitoring, reporting, communication, and evaluation system for health equity implementation plan. 

• Oversee and collaborate with stakeholder patient readmission opportunities. 

• Leads critical initiatives while coordinating with stakeholders  to ensure projects are completed on time.

• Coordinate with community health providers to organize and lead improvement efforts for chronic disease care improvement efforts.

• Analyzes trends of performance metrics, identifies opportunities for improvement, and develops action plans 

• Performs comprehensive clinical medical record review to identify quality of care risks, compile case summaries and prepare cases for committee review. Interprets quality metrics and identifies opportunities for improvement, and develops action plans 

• Collaborates with and trains individuals and teams to implement monitoring and measurement tools, and data analysis techniques 

• Facilitates quality efforts and coaches others in the development of performance improvement activities with an emphasis on process redesign and measurement 

Educational Requirements

• Graduate of an accredited school of healthcare 
• Must be able to communicate effectively in English, both verbally and in writing. 

• Bachelor’s degree in healthcare administration, business administration, nursing, or other healthcare related field . preferred

Licensure and Certifications  

• Completion of job specific orientation program within 30 days.

• Certified Professional in Healthcare Quality (CPHQ) certification preferred.

• Lean Six Sigma Yellow Belt certified or obtained within one year of hire. 

Knowledge/Skills/Abilities

• Knowledge of quality indicators and specification manuals for accreditation agencies, CMS, state regulatory agencies and professional organization certification requirements is preferred. 
• Able to apply principles and tools of performance improvement to a wide range of problems.
• Able to read and interpret medical documentation and hospital policies & procedures.

• Three years of progressive experience in provider practices or acute care setting

• Exercises good time management skills and maintains productive use of time. 

• Must have the ability to organize, delegate, make decisions, instruct, listen, and display professionalism and confidentiality.

• Articulate and able to communicate orally and/or in writing with physicians, leadership, community members and allied health professionals.

• Ability to prioritize multiple tasks and complete work under pressure of deadlines and resource constraints.

• Ability to analyze, synthesize, report, and manage patient care and practice information obtained through quality assessment reviews.

Physical Requirements

• Primarily works the day shift; additional hours may be asked to work other hours as needed, including weekends.
• Ability to distinguish between numbers and symbols.
• Hand-eye coordination and manual dexterity with substantial movement of wrist and/or fingers.
• Walking and climbing to accomplish tasks.
• Corrected vision and hearing to normal or near normal range.
• Extended periods of sitting and/or walking depending on specific duties.

Work Envir