Director of Healthcare Quality - Casa Grande - Luna Companies

    Luna Companies
    Luna Companies Casa Grande

    1 day ago

    Healthcare
    Description

    Essential Functions

    • Lead and oversee quality improvement and risk management programs within an FQHC environment
    • Develop, implement, and monitor quality metrics aligned with HRSA, CMS, state licensing, and Joint Commission standards
    • Coordinate accreditation, licensing, and regulatory surveys, including HRSA and Joint Commission activities (ICM, FSA)
    • Maintain continuous survey readiness through internal audits, performance monitoring, and ongoing compliance reviews
    • Oversee the collection, reporting, and submission of Clinical Quality Measures (CQMs) to HRSA
    • Analyze quality and risk data to identify trends, assess risk, and drive performance improvement initiatives
    • Support clinical audits, inspections, and the development and execution of corrective action plans
    • Educate providers and staff on regulatory, accreditation, quality, and patient safety standards
    • Manage incident reporting and risk management processes, and present findings to appropriate committees
    • Deliver annual risk management training and lead organization-wide risk mitigation efforts
    • Collaborate with executive leadership, providers, and operational teams to improve quality, safety, and regulatory compliance
    • Participate in peer review, quality, and risk oversight committees
    • Prepare and present quality and risk management reports to senior leadership and the Board of Directors
    • Serve as the primary point of contact for FTCA claims and litigation-related matters
    • Support organizational safety initiatives and emergency preparedness planning

    Knowledge, Skills, and Abilities

    • In-depth knowledge of HRSA, CMS, Joint Commission, and FQHC regulatory and compliance requirements
    • Strong analytical skills with the ability to interpret data, identify trends, and lead improvement efforts
    • Excellent organizational, communication, and leadership capabilities
    • Proven ability to work collaboratively across clinical, administrative, and operational teams
    • Sound professional judgment and strict adherence to confidentiality and ethical standards

    Qualifications

    Education and Experience

    • Bachelor's degree required
    • Advanced degree in healthcare administration, quality, compliance, or a related field preferred
    • Minimum of eight (8) years of progressively responsible experience with a high level of autonomy and accountability
    • At least five (5) years of leadership experience managing teams or programs
    • Licensed in the State of Arizona or eligible for licensure in Arizona
    • Clinical background preferred; Registered Nurse experience strongly preferred
    • Demonstrated ability to evaluate processes, assess workflows, and recommend improvements to enhance compliance and performance
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