We are recruiting for a Director, Quality Reporting to join our Quality & Outcomes team. Remote work will be considered for this position.

Job Summary:

Responsible for the development and management of systems and processes for the identification, collection, analysis and reporting of key performance indicators. Responsible for annual authoring of the Strategic Quality Plan (SQP). Directs annual updates of quality committee dashboards and supporting meeting documents (PIT charter and minutes template, QC evaluation form, etc.). Conducts education and training sessions to field, district, and division on all aspects of quality reporting. Collaborates with Infection Control subject matter experts in oversight and compliance evaluation of NHSN reporting. Able to audit NHSN, LTRAX and iQIES for evaluation of compliance with CMS quality reporting program and run monthly reports from them. Responsible for creation, execution, training and results evaluation of Culture of Safety survey.

Essential Functions

Leadership

• Directs the clinical outcomes reporting processes for the hospital division (customer satisfaction surveys, Benchmark Reporting, Quality and Service).
• Participates in the planning and creating operational service design and other organizational plans and policies to achieve and maintain compliance with CMS Quality Reporting Program (QRP), avoiding penalities associated with non-compliance.
• Serves as a department consultant for assessing valid and reliable data reporting methodologies that optimize support processes for internal and field customers.
• Develops, designs and provides policies and procedures that guide and support the provision and integration of services according to the mission and vision consistent with QRP compliance.
• Develops, designs and provides education on purpose and execution of all components of quality reporting processes.
• Communicates and promotes effective and efficient reporting practices, processes, systems, and operational plans to key clinical leadership.
• Integrates recognition of human factors in design and training activities; promotes a framework for safe and reliable healthcare.

Job Specific

• Develops, organizes, coordinates and makes recommendations for the overall performance and outcomes reporting outcomes program for the hospital division, key indicator development, process/systems/performance improvement methodologies and processes (Internal Quality Reports, CMS Mandatory Reporting Program, statistical process control, etc.).
• Develops hospital division performance improvement programs, facilitates dashboard indicator development and makes recommendations regarding at-risk areas or opportunities for improvement. 
• Recommends, designs, and assists in process re-engineering as necessary to ensure reliability in quality reporting.
• Tracks, trends, analyzes and reports key quality indicators. Works collaboratively with Clinical Operations and hospitals' Directors of Quality Management as appropriate to provide educational programs, tools and processes for orientation, in-service training and continuing education to ensure safe, efficient and effective data reporting.
• Provides technical expertise and consultation regarding quality management and performance improvement tools, protocols, methodologies and documentation for the hospital division. Provides and supports quality reporting reports to the Board of Directors, company, hospital division Monthly Operations Reviews (MOR), Hospital Division Quality Council (HDQC), and Hospital Division Executive Committee (HDEC) on a routine basis.
• Executes a continuous training approach to the job; creates an annual calendar of refresher courses related to QAPI, use of tools and applications used as part of QAPI and person safety activities.

Knowledge/Skills/Abilities/Expectations:

• Expert knowledge of quality management and performance improvement practices, processes, systems, standards and regulations.
• Excellent verbal and written communication skills.
• Ability to establish and maintain excellent relationship skills with team and field.
• Ability to demonstrate critical thinking, appropriate prioritization and time management skills. Independent decision-making skills.
• Approximate percent of time required to travel:   25  percent

• Must read, write and speak fluent English.
• Must have good and regular attendance.
• Approximate percent of time required to travel:  
• Performs other related duties as assigned.

Education:

• Bachelor's degree required.  Master's degree preferred.

Licenses/Certification:

• Certified Professional Healthcare Quality (CPHQ) certification, advanced skills in statistical process control, Six Sigma (Green Belt or Black Belt) or similar certification designation preferred.

Experience:

• 5 years progressively responsible experience in quality/process performance/systems management. Prefer experience in multi-hospital program or similar system quality experience. Experience in CMS Quality Reporting Program (QRP) in Post-acute Care a plus.

Depending on candidate’s qualifications, we may fill this at a different level.