Clinical Quality and Compliance Manager- Partially Remote

Website Islands Community Medical Services

This position collaborates with the Senior Leadership team on strategic planning, goal setting, department evaluations, and the implementation of strategic quality initiatives for ICMS. The ICMS Quality and Compliance Manager works in partnership with administrative and medical staff leadership and provides leadership in the development of a culture of safety and measurement of the quality of care identifying opportunities and strategies for performance improvement. Directs and coordinates accreditation, policy, and regulatory affairs initiatives for ICMS and serves as the liaison to quality partnerships (CCPM, Maine Primary Care Association, Maine Medical Association, etc.) and other pertinent regulatory agencies.


·         Initiates and oversees the development of a comprehensive quality improvement program inclusive of the analysis and trending of data related to initiatives. Must demonstrate integrity, sound judgment, demonstrated leadership skills, and strong interpersonal skills. Must be able to approach staff about quality issues with tact and diplomacy.

·         Provides strategic oversight of quality improvement workgroups with accountability for distribution of organizational communication within ICMS. Excellent oral and written communication skills needed, strong organizational ability required.

·         Provides overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and HRSA, and standards including the National Committee of Quality Assurance that are evidence- based. Must be familiar with PCMH accreditation.

·         Interprets and coordinates compliance with the HRSA Compliance Manual, and other Federal, State and local regulations that are applicable to these practices. Experience working with disadvantaged populations helpful and knowledge of health disparities highly desired. Assist with annual UDS and HRSA reports.

·         Prepares reports and assesses compliance with accreditation standards and regulations related to clinical care in collaboration with ICMS leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.

·         In conjunction with clinical staff and medical staff directs and coordinates quality improvement initiatives. Assists in the development, monitoring, and presentation of internal quality measures and initiatives. Coordinating tracking and reporting of clinical and utilization outcomes, and follow-up of corrective action plans.

·         Proactively educates leadership, clinicians, and staff regarding the basic of risk management/patient safety and their role in ensuring that patients are not harmed during care delivery.

·         In collaboration with clinical staff and service managers, participates in the monitoring, reporting, and improvement activities related to clinical care, health care quality/safety initiatives, accreditation, and regulatory requirements.

·         Participates and coordinates various committees and projects to facilitate the compliance of regulatory and needs of the position responsibilities.

·         Regularly communicates quality activities to leadership and staff. Outstanding skills in data collection, analysis, and presentation. Experience in the use of spreadsheets (e.g. Excel) for QI-related data management.

Degree in Nursing, Health Informatics, Public Health or a related discipline required. Master’s Degree preferred but individuals with experience in leading a quality improvement program may be considered.

Three years minimum of progressive administrative leadership experience in quality and patient safety activities with demonstrated ability in design and implementation of performance improvement activities in a health care setting including skillful application of continuous quality improvement and patient safety sciences. Experience in Lean as an improvement methodology is preferred.

RN License required if qualifying based on Nursing degree.

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