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Manager Quality

CHI Saint Joseph Health System Lexington, Kentucky
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The posted compensation range of $35.12 - $50.92 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

Requisition ID 2025-418025 Employment Type Full Time Department Quality Management Hours/Pay Period 80 Shift Day Weekly Schedule Monday - Friday 0800-1700 Remote No Category Risk and Compliance

Responsibilities

JOB SUMMARY / PURPOSE
Responsible for the implementation and management of the Performance Improvement (PI) plan and maintaining compliance with Joint Commission and relevant State and Federal regulations related to quality monitoring and performance improvement. Oversees the day- to-day operations of the Quality Management staff.

ESSENTIAL KEY JOB RESPONSIBILITIES

  • Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) and medical staff departments, committees, divisions, service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement.
  • Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.
  • Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers. Provides consultation and assists physicians, ancillary and nursing departments with regulatory compliance issues. Supports implementation of regulatory initiatives.
  • Provides leadership to the Quality Management Department; hires, supervises, and monitors staff performance and productivity. Contributes to the budgeting process.
  • Educates and trains staff and physicians in quality improvement including the aggregation and analysis, action planning and reporting of performance data.
  • Other duties as assigned by management.
    *Reporting Structure may differ in Critical Access Hospitals

Qualifications

Required Education and Experience

  • Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.
  • Minimum of three (3) years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization’s Quality Improvement Program.
  • Minimum of two (2) years of clinical, patient care experience or equivalent.
  • Experience with quality improvement methodology and data analysis
  • Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.

Required Licensure and Certifications

  • Current state license in a clinical field; 5 (five) years’ experience in Quality Management can be used in lieu of state license.
  • Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
Overview

Welcome to Saint Joseph Hospital, a 433-bed hospital founded in 1877 by the Sisters of Charity of Nazareth as the first hospital in Lexington, Kentucky. Led by Sister Euphrasia Stafford, the mission to provide compassionate care to the underserved is still carried out today. Saint Joseph Hospital holds over two dozen national ranks and recognitions and is recognized as a 2024 Best Place to Work in Kentucky. 

Saint Joseph is part of CommonSpirit Health, a non-profit, Catholic health system dedicated to advancing health for all people. With approximately 175,000 employees and 25,000 physicians and advanced practice clinicians. 

Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians, advanced practice clinicians, nurses, and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2,200 care centers serving 24 states. 

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.

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Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible employees may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit https://www.commonspirit.careers/benefits.

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Equal Opportunity

CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here [PDF].

CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.