Quality Improvement Specialist

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Employee Benefits:

DSHS offers insurance coverage and other benefits available through the State of Texas Group Benefits Plan administered by the Employee Retirement System of Texas (ERS). To learn more about all the benefits available to you as a DSHS employee and other DSHS opportunities for early career pathways visit the DSHS Careers Page.

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Functional Title:Quality Improvement Specialist
Job Title:Program Specialist I
Agency:Dept of State Health Services
Department:TX Ctr for Infectious Disease
Posting Number:18004
Closing Date:06/30/2026
Posting Audience:Internal and External
Occupational Category:Healthcare Support
Salary Range:$4583.00-$5372.41
Pay Frequency: Monthly
Salary Group:TEXAS-B-17
Shift:Compressed Weekend
Additional Shift:Days (First)
Telework:Not Eligible for Telework
Travel:Up to 5%
Regular/Temporary:Regular
Full Time/Part Time:Full time
FLSA Exempt/Non-Exempt:Exempt
Facility Location:Texas Center for Infectious Disease
Job Location City:SAN ANTONIO
Job Location Address:2303 SE MILITARY DR
Other Locations:San Antonio
MOS Codes: 16GX60C0611X612X63G0641X712X86M08U000OSOSSPERSYNYNS

Brief Job Description:

Under the supervision of the Director of Quality Management the Program Specialist I in Quality Management (QM) assists in coordinating the compliance evaluation and continuous improvement of healthcare services and programs within the hospital. This position supports hospital compliance with Joint Commission Centers for Medicare & Medicaid Services (CMS) and applicable state and departmental regulatory standards.

Primary responsibilities include researching regulatory standards developing and maintaining hospital policies and procedures conducting routine audits and mock tracers supporting mock survey activities and assisting with the development and monitoring of Plans of Correction (POCs) for identified compliance gaps. The Program Specialist I works closely with the Quality Management team hospital leadership medical staff and operational departments to support accreditation readiness and ongoing quality improvement efforts.

This position works under limited supervision with latitude for initiative and independent judgment within established guidelines.

Essential Job Functions (EJFs):

Attends work on a regular and predictable schedule in accordance with agency leave policy. 5%

Monitors hospital compliance with Joint Commission CMS and applicable state regulatory standards by conducting regulatory reviews tracking compliance activities identifying gaps and supporting ongoing survey readiness efforts. 10%

Researches interprets and applies Joint Commission CMS and state regulatory requirements and develops revises and maintains hospital policies and procedures to ensure alignment with current standards and regulatory expectations. 10%

Conducts mock tracers mock surveys and compliance audits to evaluate accreditation readiness assess adherence to regulatory requirements identify opportunities for improvement and monitor implementation of corrective actions. 15%

Collects analyzes and reports quality patient safety infection prevention regulatory compliance and performance improvement data; develops dashboards trend analyses and recommendations to support organizational decision-making and performance improvement initiatives.15%

Coordinates the development implementation and monitoring of Plans of Correction (POCs) corrective action plans and accreditation evidence collection and regulatory readiness activities; collaborates with hospital departments to ensure timely resolution of identified compliance gaps.15%

Assists with the coordination documentation and follow-up of hospital committees and workgroups ensuring quality patient safety accreditation and compliance related activities are appropriately tracked and addressed. 15%

Participates and leads quality improvement activities including Root Cause Analysis Failure Mode and Effect Analyses patient tracers and performance improvement projects designed to improve patient safety quality of care regulatory compliance and organization performance. 10%

Performs other duties as assigned including participation in disaster response emergency preparedness and Continuity of Operations (COOP) activities. 5%

Knowledge Skills and Abilities (KSAs):

Knowledge of or experience with Joint Commission and CMS accreditation standards and healthcare regulatory requirements.

Knowledge of policy and procedure development revision and document control processes.

Knowledge of performance improvement and quality management principles.

Strong written and verbal communication skills.

Proficiency in Microsoft Word Excel and PowerPoint.

Skill in preparing reports and tracking compliance and corrective actions.

Ability to work collaboratively with multidisciplinary teams.

Ability to interpret and apply regulatory requirements in operational and clinical settings.

Ability to analyze data and present findings clearly and accurately.

Ability to conduct or participate in mock tracers mock surveys and compliance audits in a hospital or clinical environment.

Registrations Licensure Requirements or Certifications:

None required

Initial Screening Criteria:

Bachelors degree or higher from an accredited college or university.

Minimum of two years of professional experience in a healthcare setting.

Minimum of two years of experience in healthcare quality management accreditation regulatory compliance performance improvement policy development nursing social work public health healthcare administration infection prevention or risk management.

Additional Information:

MOS Code: N/A

Active Duty Military Reservists Guardsmen and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include but not limited to those listed in this posting. All active-duty military reservists guardsmen and veterans are encouraged to apply if qualified for this position. For more information see the Texas State Auditors Military Crosswalk at Accommodations:

In compliance with the Americans with Disabilities Act (ADA) DSHS will provide reasonable accommodation during the hiring process for individuals with a qualifying disability. If reasonable accommodation is needed to participate in the interview process please notify the person who contacts you to schedule the interview. If you need assistance completing the on-line application contact the HHS Employee Service Center at 1- or via email at .

Salary Information Pre-employment Checks and Work Eligibility:

• The salary offered will follow DSHS starting salary guidelines. Any employment offer is contingent upon available budgeted funds.
• Depending on the program area and position requirements applicants selected for hire may be required to pass background and other due diligence checks.
• DSHS uses E-Verify. You must bring your I-9 documentation with you on your first day of work.Download the I-9 form