Essential Functions and Responsibilities:

Strategic Leadership

• Design and execute strategies to elevate clinical quality, patient safety, and care outcomes across all network sites and affiliates.

• Align quality initiatives with organizational goals, value-based care models, and population health strategies.

• Responsible for annual Network clinical quality, patient safety/risk plans aligned with Medical Center plans and organization’s strategic goals.

Performance Improvement

• Lead and sustain network-wide performance improvement projects using evidence-based methodologies.

• Provide consultation for Network leaders and Performance Improvement teams on Improvement strategies and best practices.

• Promote a proactive approach to identifying and resolving gaps in care processes and patient outcomes.

• Manage assigned clinical quality staff and cross functional improvement teams .

• Work collaboratively with Medical Center and UCSF data analytics and Population Health teams to drive successful performance improvement and metrics development.

Regulatory Compliance

• Ensure continuous compliance with all relevant state and federal healthcare regulations, payer standards, and risk-based program requirements.

• Maintain organizational readiness for audits and reporting, with a focus on quality integrity and transparency.

• Collaborate with Medical Center Accreditation, Regulatory License Manager to ensure Outpatient sites under the Medical Center license sustain compliance with Medical Center policies and compliance standards.

• Leads compliance complaint investigations and coordinates/ develops corrective action plans, responses and monitors through resolution.

Clinical Data & Analytics

• Oversee clinical quality data collection, validation, and interpretation to guide operational and strategic decisions.

• Drive adoption of actionable insights through user-friendly dashboards and reports for medical staff and leadership.

• Liaison to Medical Center QMS data analytics team.

Collaboration & Partnerships

• Foster deep partnerships with UCSF Health, enhancing integration of academic-level clinical excellence into community practice.

• Serve as a strategic partner to Partnership HealthPlan and other IPAs, supporting value-based performance metrics and collaborative improvement initiatives.

• Facilitate shared learning, peer benchmarking, and coordinated quality programs across the network.

Technology & Informatics

• Consult with Informatics leads regarding the use of APEX (Epic-based EHR platform) to optimize clinical workflows, track key performance indicators, and support data-driven decision-making.

• Lead the use of APEX (Epic-based EHR platform) to optimize clinical workflows, track key performance indicators, and support data-driven decision-making.

• Collaborate with IT and clinical informatics teams to ensure accurate reporting, system optimization, and provider engagement.

MIPS Strategy & Optimization

• Develop and manage organizational strategy for Merit-Based Incentive Payment System (MIPS) reporting.

• Ensure accuracy, compliance, and continuous improvement in CMS quality program participation to maximize organizational performance and reimbursement.

Patient Complaints/Grievances

• Serves as Outpatient Quality representative to enterprise Patient complaints/Grievances Committee.

• Responsible for investigation and response to Outpatient Patient Grievances reported through insurers and external regulatory agencies.

• Collaborates with Patient Experience and Relations staff to address patient grievances evolving to consideration of patient terminations.

• Ensures patient terminations follow regulatory, accreditation standards.

Patient Safety/Risk Peer Review

• Responsible for Network Patient Safety Event System (PSES) fostering safety event reporting, investigation and response using Just Culture philosophy and strategies.

• Partner with Risk Manager on Serious Safety Event investigation, communication and response following BETA HEART strategies.

• Manage assigned staff and support Network Quality and Medical Staff Peer Review committees and processes.

• Represent Network on enterprise QMS teams developing quality and risk data systems.

• Serves on Outpatient Threat Management Team.

Culture of Quality & Patient Safety

• Champion a culture of continuous learning and accountability through, clinical quality and patient safety training programs, and leadership development.

• Responsible for Network participation in BETA Health: HEART training programs, SCORE safety culture survey and BETA Health: HEART event response team.

• Serve as a mentor and coach to teams across the network, promoting alignment and best practice adoption.

Infection Prevention & Control

• Liaison to Medical Center Infection Control Program Manager for Network Infection Control

• Manages outpatient Infection Control program and outpatient Infection Control staff including staff IC education, routine environment of Care rounds, disease outbreak response, hand hygiene program, infection prevention to ensure compliance with Infection Control standards and regulatory requirements.

Outpatient Clinical Research Activity

• Liaison to local IRB coordinator for new research protocol review or renewals.

• Supports clinical research participation and compliance through collaboration with MHMC QMS research staff.

Qualifications:

Education

• Master’s degree in Nursing (MSN), Pharmacy (PharmD), Healthcare Administration (MHA), Public Health (MPH), or a closely related healthcare field preferred.

• Bachelor’s degree in Nursing or a related healthcare field required.

• A non-healthcare Bachelor’s degree may be considered only if accompanied by a Master’s or Doctoral degree in a healthcare-related field.

Licenses/Certifications
Required:

• Active, unrestricted Registered Nurse (RN) License or Doctor of Pharmacy (PharmD) with active licensure to practice.

Preferred:

• Certified Professional in Healthcare Quality (CPHQ)

• Certified Professional in Patient Safety (CPPS)

• Certification in Infection Control (CIC)

Experience

• Minimum of 5 years of progressive leadership in clinical quality, performance improvement, or patient safety within an acute care or ambulatory setting.

• At least 3 years in a management or director-level position within a clinically integrated or value-based care environment.

• Demonstrated success in leading cross-functional initiatives, leveraging data analytics, and engaging physician leadership in quality programs.

• Experience with EPIC/APEX systems and MIPS reporting platforms.

Skills & Competencies

• Strong analytical and critical thinking capabilities.

• Exceptional written and verbal communication skills.

• Advanced proficiency in quality measurement, reporting tools, and health informatics.

• Proven ability to drive cultural transformation and lead multi-site quality programs.

• Effective at managing complex projects with competing priorities and deadlines.