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Location: Administration

Report to : President/Chief Executive Officer for Compliance Program Chief Medical Officer (CMO) for Quality Improvement Program

ADA : Full time position. Ability to sit and perform computer entry work for duration of work day. Must be able to drive to all locations.

OSHA : Must adhere to universal precautions, to include blood borne pathogen protection, at all times.


This is a highly responsible position that is directly under the supervision of the Chief Executive Officer and Chief Medical Officer for its two components. The person holding this position is expected to provide leadership, technical expertise and management of the Corporation's Quality Improvement and Compliance Program. The person holding this position works in collaboration with the Senior leadership team, the Clinical Support Services Coordinator and leadership at the Center level.

Job Requirements

  1. In conjunction with the Quality Improvement Coordinators, performs data retrieval for performance improvement activities as indicated. This includes but is not limited to: Chart audits, management reports, and incident reports.

  2. Prepares, or has prepared, all information for Corporate QI meeting; i.e. minutes, hand-outs, performance improvement plans (PIPs), etc.

  3. Coordinates and establishes timetables for QI/QA departmental procedure manual updates. With the assistance of the QI staff and leadership teams, determines Quality Improvement/ Quality Assurance objectives and activities for the upcoming year.

  4. Keeps CMO informed regarding the organization’s QI/QA performance status and issues at all times.

  5. Stay current with regulations, laws, PI methodology and QI/QA associated measurement tools through continuing education (NACHC, FACHC, AHIMA, meetings, trainings, and other program related agencies and activities).

  6. Develop and provide training (directly or via designees) regarding the QI/QA plan, process, and activities for all employees.

  7. Provide leadership, supervision, and training for members of the QI department.


  1. Responsible for the development and implementation of the Quality Improvement/Quality Assurance Plan and the Corporate Compliance Plan.

  2. Responsible for the annual review and update of the organization’s Quality Improvement/Quality Assurance Plan and Compliance Plan and providing leadership for the company-wide Performance Improvement processes.

  3. Chairs Board and Corporate Quality Improvement/Safety Committees to be held every month.

  4. Monitors laboratories, in conjunction with the Laboratory Coordinator, for compliance with CLIA regulations. Keeps the Florida State and CLIA licenses current and up to date. Notifies appropriate agencies as changes are made.

  5. Responsible for incident reporting (receiving incident reports and reviewing them with the appropriate Senior leadership). This also includes providing direction of completing root-cause analysis (RCA) and recommending performance improvement plans in response to adverse incidents.

  6. Submits monthly QI/RISK management reports to the Board of Directors (BOD). This includes information regarding FCHC Quality Measure performance and associated QI/QA activities. Regularly provides updates regarding TJC and PCMH status to the BOD. Leads the monthly BOD QI Committee. Assures the BOD reviews and approves the Corporate QI/QA plan no less than annually.

  7. Works with Senior and Center Management to assist and ensure compliance with the QI Plan and Corporate Compliance Plan with internal (policy/procedure) and external (contract/program) requirements.

  8. Participate with regional networks, if applicable.

  9. Facilitates, with the assistance of Senior Management, the development tools, guides, brochures, surveys, etc., necessary for the corporate compliance and QI/QA programs of FCHC.

  10. Performs other duties relating to Quality Improvement and Corporate Compliance as may be directed by the Chie f Medical Officer and Chief Executive Officer, respectively.


  1. Maintains employee hotline and monitors for complaints and potential fraud/abuse reports.

  2. Responsible for investigating all reports of potentially improper/illegal activities and reporting results to CEO and Board of Directors.

  3. Responsible for handling and responding to medical malpractice claims or allegations (compiling medical records, completing documentation responses for Administrative Tort Claims and informational requests, and disseminating litigation hold notices)

  4. Responsible for overseeing status updates to medical malpractice claims or allegations (updating files with received notices and maintaining records for FTCA application updates). This also includes providing the Board of Directors a status report at monthly meetings

  5. Keeps CEO informed regardin g Compliance status and issues of the Corporation at all times.

  6. Develop training for all employees in corporate compliance requirements.

  7. In coordination with the CEO, keeps current with relevant OIG, CMS, Federal, State and local regulations and laws, fraud alerts, and other regulatory agency rules and regulations.

Minimum Qualifications:

  1. Must possess a minimum of a MD/DO, RN or appropriate Masters level degree
  2. Must have at least five (5) years experience in quality improvement related activities and management experience. Knowledge of statistics, data collection, and survey design helpful.


  1. Must be able and willing to travel within six (6) county service area and outside the area to occasional workshop and/or conference.

  2. Must be computer literate.

  3. Must demonstrate leadership ability

  4. Knowledge of management techniques and procedures necessary for problem solving, conflict resolution, and program development.

  5. Knowledge of health care delivery systems, inclusive of medical records.

  6. Knowledge of CLIA 88 regulations.

  7. Knowledge of quality improvement standards as they relate to ambulatory centers.

  8. Knowledge of current Federal, State and local laws and regulations.

  9. Ability to collect and analyze quality improvement data in a timely manner.

  10. Ability to implement quality improvement policy accurately and consistently.

  11. Ability to work cooperatively with all department supervisors to develop QI activity schedule.

  12. Ability to keep all data collected in a neat, organized manner.

  13. Ability to communicate clearly in written and interpersonal communications.

**This job description is not intended to be all-inclusive, and employee will also perform other reasonable related business duties as assigned by supervisor.

  • This organization reserves the right to revise or change job duties and responsibilities as the need arises. This job description does not constitute a written or implied contract of employment.

Location All
Status Director
Time Full Time
Date Added 19 March 2020
Contract Employment Contract
Category: Administrator
Company name Florida Community Health Centers
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Since 1976, Florida Community Health Centers Inc. has been a leader in providing health care services in Florida. Comprehensive primary health care services are provided through a network of health centers surrounding Lake Okeechobee and throughout Florida’s Treasure Coast.  

FCHC has health center locations in Clewiston, Fort Pierce, Indiantown, Moore Haven, Okeechobee,  Pahokee, Port St. Lucie, and Stuart with FCHC’s Corporate Office centrally located in West Palm Beach, Florida. There are over 400 employees, in which 100 are clinicians. FCHC has multiple staff members who speak Spanish and Creole, and translation is available for other languages as needed. FCHC has created a “one-stop shop” for patients providing pediatric, adult primary, dental, OB/GYN and pharmacy services, with an option to have prescriptions delivered by mail.Our patients benefit from a “medical home” model, where they may access and benefit from our extensive array of health care clinicians and services at each location. FCHC is starting the process to expand our behavioral health and susbstance use disorder services.

Utilizing a sliding fee scale (SFS), based on annual federal poverty limits (FPL), we are able to determine the amount of financial responsibility each patient carries regarding their health care services. Patients who are at or below 100% of FPL have their health care needs provided by FCHC at a nominal charge.

FCHC is a private, non-profit, tax exempt 501(c)3, consumer directed corporation designated as a Federally Qualified Health Center (FQHC), and accredited by The Joint Commission (JC), as well as recognized as a Level 3 Patient Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA).


The Mission of Florida Community Health Centers, Inc. (FCHC) is to provide accessible, cost-effective, high-quality, comprehensive health care to all persons in our communities.


Florida Community Health Centers, Inc. (FCHC) will maintain strong leadership in, and advocate for, the provision of health care services.

FCHC will foster and promote collaborative relationships and will develop partnerships with local, state, and federal public health service agencies and the community in general, to enhance the quality of delivery systems for comprehensive health care. FCHC will be an employer of choice and will demonstrate excellence with a highly trained staff and governing board.


FCHC values Integrity, Compassion, Commitment to serving others (external and internal to the organization), Innovation, Effectiveness (cost and outcome), Efficiency, being Mission-driven, and Commitment to excellence.


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