Position Summary
The Quality Management & Improvement Program Manager provides leadership, coordination, and oversight of the organization's Quality Management and Improvement (QM&I) Program. This role ensures compliance with accreditation and regulatory standards, including AAAHC, NCQA, HRSA, and IHS requirements, while promoting a culture of continuous quality improvement across the organization.
Essential Duties and Responsibilities
Program Leadership & Oversight
- Lead the design, implementation, and ongoing management of the Quality Management and Improvement Program.
- Oversee execution of the Quality Improvement Plan, including development of annual work plans, evaluation of outcomes, and preparation of annual reports to the Board of Directors.
- Coordinate and submit regular quality improvement reports to the Board of Directors and Quality Management & Improvement Committee.
- Lead the coordination and documentation of quality improvement infrastructure across all departments.
- Develop, standardize, monitor and oversee use of quality improvement methodologies, including PDSA frameworks across all departments.
- Ensure all departments maintain active quality improvement initiatives supported by accurate and timely data.
- Provide project management support for clinical quality metrics and improvement workflows.
- Provide education, training, and coaching to staff and leadership on quality improvement principles, accreditation standards, and regulatory requirements.
- Coordinate patient experience survey processes and ensure analysis of trends and opportunities for improvement.
- Support departments in aligning quality improvement initiatives with organizational priorities and regulatory standards.
Accreditation, Compliance & Regulatory Readiness
- Serve as the primary point of contact for accreditation and survey readiness activities by leading and coordinating AAAHC accreditation, NCQA recognition/reporting, HRSA audits, and IHS audits.
- Conduct mock surveys and prepare staff and leadership for on-site reviews.
- Maintain documentation and crosswalks demonstrating compliance with all applicable standards and regulations.
Policy & Documentation Management
- Lead policy development, review, tracking, and compliance oversight.
- Ensure organizational policies and process maps align with AAAHC and NCQA standards.
- Manage the Compliatric Document Management System to support policy lifecycle and compliance tracking.
Collaboration & Data Integration
- Collaborate with Health Information Technology (HIT), Risk Management and clinical leadership to align quality metrics with accreditation and regulatory requirements (e.g., CMS eCQMs, UDS measures).
- Develop and maintain organizational and departmental performance dashboards.
- Coordinate, facilitate, and participate in organizational committees and workgroups, including Quality Improvement & Management, PCMH, Compliance/Policy, Infection Control and Prevention and Safety, and Peer Review.
- Perform other related duties as assigned.
Knowledge, Skills & Abilities
Management & Compliance
- Knowledge of organizational administration, fiscal/personnel management, and applicable local, State of Wisconsin, and federal regulations
- Skilled in qualitative/quantitative, financial, and operational analysis across healthcare systems, business processes, and project management
- Experience with electronic document management and accreditation platforms (e.g., Compliatric, NCQA QPASS, AAAHC 1095 Engage), including uploading and managing supporting documentation.
- Proficient in Microsoft Office (Word, Excel) and information systems
- Demonstrated knowledge of, and at least 5 years of experience with, regulatory and accreditation requirements, including AAAHC, NCQA, IHS, and HRSA standards.
Leadership & Problem Solving
- Proven leadership, team-building, influencing skills and demonstrates cultural competence
- Strong critical thinking, creativity, and complex problem resolution
- Effective communicator with strong interpersonal and customer service skills
- Able to build relationships, work across diverse teams, and drive consensus
- Highly organized, detail-oriented, and reliable; able to prioritize, multi-task, and adapt in dynamic environments
Education & Qualifications
- Minimum required qualification is a Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field.
- Master's degree in Nursing, Healthcare Administration, Public Health, or a related field is preferred.
- Minimum of 3 years of experience in healthcare quality improvement, or a minimum of 10 years of experience in healthcare administration or clinical practice.
- Proven experience with standardized clinical quality measures, data analytics, AAAHC quality improvement studies, Plan-Do-Study-Act (PDSA) cycles, and established quality improvement frameworks.
- Clinical experience in a primary care setting is preferred.
- Experience with EPIC OCHIN or other electronic health record (EHR) systems is preferred.
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Gerald L. Ignace Indian Health Center, Inc.
$85,000 - $ 90,000 - As an approved site for federal loan repayment programs, we offer qualified clinicians opportunities to reduce student debt while serving our community. Options include the NHSC Loan Repayment Program ($50,000-$75,000 for two years) a
Jun 04, 2026