Quality Improvement Manager

GENERAL SUMMARY

This role is responsible for overseeing a variety of quality improvement programs. Leads clinical quality programs and improvements initiatives that align with organizational and strategic objectives. Utilizing improvement methodology this role will facilitate and lead projects to achieve intended clinical or operational outcomes. Under the general guidance of the Senior Director for Quality fosters a Zero Harm environment while promoting the principles of a High Reliability Organization.

PRINCIPAL RESPONSIBILITIES AND TASKS

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Under guidance and partnership with the leader supports various Pay for Performance programs including but not limited to MHACs QBR PSIs and Mortality to achieve high performance.
• Perform retrospective chart audits for key quality metrics (PPCs PSIs and unexpected deaths) and identify improvement opportunities in clinical and/or documentation processes.
• Analyzes performance metrics in clinical procedures and operational performance to identify potential trends or root causes.
• Works collaboratively with department leadership to develop and implement the hospital level strategic plan for quality and safety.
• Partners to facilitate and implement improvements in all clinical and documentation practices in support of organizational and departmental objectives.
• Participates in regulatory activities including Joint Commission and CMS Surveys.
• Primary support and leads Leapfrog action item planning and survey completion.
• Leads or facilitates clinical improvement teams to identify plan implement and sustain change for identified improvement opportunities using relevant quality tools and timelines.
• Prepares formal presentations of the quality results and presents to the appropriate committee(s).
• Responds to requests for explanation from Payors for Quality of Care letters or clinical concerns.
• Represents the team and offers quality improvement expertise in committee meetings as needed.
• Manages and supervises quality team members including hiring performance management evaluations directs and reviews work and terminations.
• Promotes an engaged healthy work environment for team members by establishing a climate of support growth challenge and development of all team members
• Develops and recommends department operating budget and manages resources according to approved budget.
• Performs other duties as assigned.

Qualifications :

EDUCATION AND EXPERIENCE

• Bachelors degree in healthcare field required. Masters degree in healthcare field preferred.
• Current CPHQ certification or successfully obtain certification within 18 months of hire is required.
• Valid RN license in the local area serving (State of Maryland); or other licensure in healthcare related field is required.
• A minimum of (4) four years experience in acute care required.
• Minimum of (2) two years experience in Quality Improvement or related fields required.
• Previous experience with Marylands Pay for Performance and Quality Based Reimbursement (QBR) programs preferred.
• Program or project management experience preferred.
• Pervious leadership or supervisory experience preferred.

KNOWLEDGE SKILLS AND ABILITIES:

• Demonstrate organization problem-solving skills and team leadership skills.
• Strong current clinical knowledge and experience in an inpatient acute care setting
• Proven ability for collecting tracking and analyzing quality metric data that includes a relevant understanding of data output in support of organizational and system goals.
• Strong written and verbal communication skills

Additional Information :

All your information will be kept confidential according to EEO guidelines.

Compensation:
Pay Range: $44.76 - $67.19
Other Compensation (if applicable):
Review the 2025-2026 UMMS Benefits Guide

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Remote Work :

No

Employment Type :

Full-time