CQI Manager

ROLE SUMMARY

The Clinical Quality Improvement (CQI) Manager is responsible for leading the organization's clinical quality assurance and improvement program. This position develops, implements, and monitors quality initiatives designed to ensure compliance with federal, state, local, and accreditation standards while improving patient care outcomes, documentation quality, operational effectiveness, and clinical performance. The CQI Manager serves as a key liaison between operations, training, clinical leadership, compliance, and regulatory agencies.

This is a Exempt/Salaried position.

KEY RESPONSIBILITIES

Essential Functions / Primary Responsibilities

Quality Management & Compliance

• Develop, implement, and maintain the Clinical Quality Improvement Program.
• Monitor compliance with state EMS regulations, ICEMA requirements, Medicare documentation standards, and company clinical protocols.
• Oversee quality assurance reviews of patient care reports (PCRs), clinical incidents, and operational performance metrics.
• Ensure compliance with accreditation and regulatory standards.
• Lead preparation for regulatory inspections, audits, and accreditation reviews.

Clinical Performance Monitoring

• Establish and monitor key performance indicators (KPIs) related to patient care and documentation quality.
• Analyze clinical trends and identify opportunities for improvement.
• Develop corrective action plans and monitor effectiveness.
• Conduct root cause analyses for adverse events and significant clinical occurrences.

Leadership & Program Management

• Supervise CQI Specialists and other quality personnel.
• Provide coaching and guidance to field personnel regarding clinical documentation and protocol compliance.
• Collaborate with Operations, Training, Compliance, and Human Resources regarding performance improvement initiatives.
• Present quality findings and recommendations to executive leadership.

Education & Process Improvement

• Develop educational programs based on quality review findings.
• Support remediation and performance improvement initiatives.
• Participate in protocol review and revision processes.
• Assist with implementation of evidence-based clinical practices.

Data Analytics & Reporting

• Generate monthly, quarterly, and annual quality reports.
• Monitor clinical outcomes and documentation trends.
• Utilize ESO and other reporting systems to identify performance gaps.
• Present quality metrics to leadership and clinical committees.

#IND1

REQUIRED QUALIFICATIONS

Minimum Qualifications

Education

• Associate degree required.
• Bachelor's degree in EMS, Nursing, Healthcare Administration, Public Health, or related field preferred.

Experience

• Minimum 5 years EMS experience.
• Minimum 3 years leadership, CQI, clinical education, or compliance experience.
• Experience with EMS quality improvement programs preferred.
• Experience with ESO reporting systems preferred.

Licensure/Certification

• California Paramedic or Registered Nurse preferred.
• Current CPR certification.
• Valid driver's license.

Knowledge, Skills, and Abilities

• Knowledge of California EMS regulations and ICEMA requirements.
• Strong analytical and data interpretation skills.
• Excellent written and verbal communication skills.
• Ability to manage multiple projects simultaneously.
• Advanced proficiency with Microsoft Office and reporting software.

PHYSICAL REQUIREMENTS

The employee must be able to perform the essential functions of the position with or without reasonable accommodation.

The employee frequently:

• Ability to sit or stand for extended periods.
• Ability to utilize computers and multiple monitors for prolonged periods.
• Ability to review electronic patient care records and reporting systems for extended periods.
• Ability to occasionally travel between operational locations.
• Ability to perform all essential functions of the position with or without reasonable accommodation.

CORE COMPETENCIES

Strategic Leadership

• Provides leadership and direction for the organization's Clinical Quality Improvement Program while aligning quality initiatives with organizational goals, regulatory requirements, and patient care objectives.

Quality Improvement Expertise

• Demonstrates advanced knowledge of quality assurance methodologies, performance improvement processes, accreditation standards, and healthcare quality management principles.

Regulatory and Accreditation Knowledge

• Maintains expertise in California EMS regulations, ICEMA requirements, accreditation standards, Medicare compliance, and applicable federal, state, and local regulations.

Data Analytics and Decision Making

• Utilizes quantitative and qualitative data to evaluate performance, identify trends, measure outcomes, and support strategic decision-making.

Change Management

• Leads quality improvement initiatives and facilitates organizational change by gaining stakeholder engagement, building consensus, and promoting accountability.

Leadership and Team Development

• Provides coaching, mentoring, and performance management to CQI personnel while fostering a culture of accountability, collaboration, and continuous improvement.

Investigation and Root Cause Analysis

• Leads investigations of significant clinical events, compliance concerns, and quality issues while ensuring objective, fact-based analysis and resolution.

Communication and Influence

• Effectively communicates complex clinical and regulatory information to field personnel, physicians, operational leaders, executive leadership, regulatory agencies, and external stakeholders.

Collaboration and Relationship Building

• Develops effective working relationships with Medical Directors, Operations Leadership, Clinical Education, Compliance, Human Resources, Billing, Regulatory Agencies, and Executive Leadership.

Organizational Effectiveness

• Demonstrates strong planning, prioritization, project management, and execution skills while managing multiple initiatives and deadlines.

REPORTING RELATIONSHIP

Reports directly to the Director of Clinical Services or Regional Clinical Director.

WORK ENVIRONMENT

• The CQI Manager works primarily in a professional office environment and regularly utilizes computers, data analytics software, reporting systems, and electronic patient care record systems to oversee quality improvement activities and organizational performance.
• The position requires frequent interaction with operational leadership, Medical Directors, educators, regulatory agencies, healthcare partners, and executive leadership. Responsibilities include participation in meetings, audits, investigations, accreditation activities, quality committees, and strategic planning initiatives.
• The CQI Manager may travel throughout the service area to conduct audits, investigations, site visits, training activities, regulatory meetings, and leadership meetings. Occasional travel outside the service area may be required.
• Work schedules may require flexibility beyond normal business hours to support significant clinical events, regulatory deadlines, accreditation activities, operational needs, or urgent investigations.
• The employee routinely handles highly confidential patient, employee, quality assurance, legal, and organizational information and must exercise discretion, professionalism, and independent judgment at all times.