RN Quality Improvement & Metrics Manager

POSITION SUMMARY:

The RN Quality Improvement & Metrics Manager is responsible for leading the organization’s quality improvement, performance measurement, regulatory compliance, and population health initiatives. This role partners with clinical and operational leaders to improve patient outcomes, enhance access to care, optimize value-based reimbursement, and ensure compliance with Health Resources and Services Administration (HRSA) requirements and other regulatory standards.

The successful candidate will use clinical expertise, data analysis, evidence-based practice, and performance improvement methodologies to strengthen organizational quality programs and support the mission of providing high-quality, patient-centered care to medically underserved communities.

Mission Alignment

The RN Quality Improvement & Metrics Manager is committed to advancing the mission of the health center by improving access, quality, equity, and patient outcomes for the communities we serve. This position promotes a culture of continuous improvement and supports the organization’s commitment to delivering high-quality, affordable, and patient-centered primary care.

This version is aligned with HRSA expectations and reflects the responsibilities typically expected of an FQHC quality leader. It can also be further customized if your health center participates in specific programs such as Accountable Care Organizations (ACOs), Medicare Shared Savings Program (MSSP), or state Medicaid value-based payment initiatives.

ESSENTIAL FUNCTIONS:

Quality Improvement 

• Develop, implement, and evaluate organization-wide quality improvement initiatives. 
• Lead Performance Improvement (PI) projects using evidence-based methodologies. 
• Facilitate Plan-Do-Study-Act (PDSA) cycles and other quality improvement strategies. 
• In collaboration with the CMO, provide education and regular feedback related to quality metrics and provider performance. 
• Monitor outcomes and recommend system improvements that enhance patient care and operational efficiency. 
• Collaborate with HIPAA Compliance Manager to prepare board reports and meeting agendas 

Quality Metrics & Performance Monitoring 

Lead monitoring and reporting of key performance measures and others as defined by HRSA health standards: 

• Clinical Quality Measures (CQMs) 
• Preventive health screenings 
• Chronic disease management outcomes 
• Diabetes control 
• Hypertension control 
• Childhood and adult immunization rates 
• Women’s preventive health measures 
• Population health outcomes 
• Develop dashboards and scorecards that communicate organizational performance to providers, leadership, and governing boards. 
• Serve as a resource for evidence-based practice and clinical quality initiatives. 

Regulatory Compliance 

Ensure compliance with: 

• HRSA Health Center Program requirements 
• Uniform Data System (UDS) reporting 
• CMS quality reporting programs 
• HIPAA regulations 
• OSHA standards 
• State Department of Health regulations 
• Patient-Centered Medical Home (PCMH) standards, when applicable 
• Federal and state quality initiatives 
• Coordinate preparation for HRSA Operational Site Visits (OSVs), accreditation surveys, and external audits. 

Population Health Management 

Collaborate with clinical teams to improve health outcomes for high-risk and vulnerable patient populations by: 

• Identifying care gaps 
• Monitoring chronic disease registries 
• Improving preventive care compliance 
• Supporting care management initiatives 
• Evaluating social determinants of health data 
• Developing interventions that improve health equity 

Data Analysis & Reporting 

• Analyze clinical, financial, and operational data to identify trends and opportunities for improvement. 
• Create meaningful dashboards using electronic health record data. 
• Present findings to executive leadership, Chief Medical Officer, Providers, and RN Administrator 
• Monitor provider quality performance and recommend improvement strategies. 
• Ensure accuracy of quality reporting submitted to HRSA and other regulatory agencies. 

 
Education 

• Educate providers and staff on quality measures and performance expectations. 
• Develop training related to quality initiatives, clinical guidelines, and regulatory requirements. 

Promote a culture of continuous quality improvement throughout the organization

POSITION REQUIREMENTS:

Education/Experience 

• Bachelor of Science in Nursing (BSN) required 
• Master’s degree in nursing, Public Health, Healthcare Administration, or related field preferred 

Licensure 

• Current unrestricted Registered Nurse (RN) license 

Skills/Abilities 

• Minimum five (5) years of nursing experience 
• Minimum three (3) years of experience in quality improvement, clinical quality, population health, regulatory compliance, or performance improvement 
• Experience within a Federally Qualified Health Center, community health center, primary care organization, or ambulatory care setting preferred 
• Experience with Value Based Care 

 
Preferred Certifications 

• Certified Professional in Healthcare Quality (CPHQ) 

 
Knowledge, Skills, and Abilities 

• Demonstrated knowledge of: 
• HRSA Health Center Program requirements 
• Uniform Data System (UDS) 
• Clinical Quality Measures (CQMs) 
• HEDIS 
• Value-Based Care 
• Population Health Management 
• Care Gap Closure 
• Chronic Disease Management 
• Evidence-Based Practice 
• Quality Improvement methodologies 
• Regulatory Compliance 
• Patient-Centered Medical Home (PCMH) 
• Health Equity initiatives 
• Social Determinants of Health (SDOH) 

Ability to: 

• Interpret complex clinical data 
• Lead interdisciplinary quality initiatives 
• Develop executive-level reports and dashboards 
• Manage multiple priorities simultaneously 
• Communicate effectively with providers, leadership, and external stakeholders 
• Build collaborative relationships across departments 

 
Technical Skills 

Experience with: 

• Electronic Health Records (eClinicalWorks, Epic, Athenahealth, NextGen, or similar) 
• Microsoft Excel (advanced) 
• Microsoft Power BI or Tableau 
• Microsoft Office 
• Clinical reporting software 
• Population health management platforms 
• Quality reporting tools 

Key Performance Indicators 

Performance will be evaluated based on: 

• Achievement of UDS performance goals 
• Improvement in Clinical Quality Measures 
• Increased preventive screening rates 
• Improved chronic disease outcomes 
• Successful HRSA Operational Site Visits 
• Timely and accurate UDS reporting 
• Increased value-based reimbursement performance 
• Reduction in care gaps 
• Completion and effectiveness of quality improvement initiatives