Manager, Quality at Rochester Regional Health – ROCHESTER, New York

Job Title: Manager, Quality

Department: Cardiovascular Services
FLSA Status: Exempt

The Manager, Cardiovascular Quality is responsible for leading quality improvement, outcomes monitoring, and clinical registry management across cardiovascular programs. This role oversees cardiovascular data abstraction and analytics, ensures compliance with national registry requirements, and partners with clinical leadership to drive performance improvement initiatives that enhance patient outcomes, safety, and program accreditation.

Quality & Performance Improvement

• Lead cardiovascular quality initiatives across interventional cardiology, electrophysiology, structural heart, cardiac surgery, and vascular programs.

• Monitor key clinical performance metrics including outcomes, complications, readmissions, and adherence to evidence-based care.

• Facilitate multidisciplinary quality committees and support case review, root cause analysis, and performance improvement initiatives.

Clinical Registry Oversight

• Oversee participation in national cardiovascular registries including those managed by the American College of Cardiology National Cardiovascular Data Registry (NCDR) and the Society of Thoracic Surgeons Adult Cardiac Surgery Database.

• Ensure accurate and timely abstraction, validation, and submission of registry data.

• Supervise cardiovascular data abstraction staff and ensure adherence to registry definitions and quality standards.

Accreditation & Regulatory Compliance

• Support cardiovascular program accreditation and certification requirements including programs recognized by The American College of Cardiology (e.g., Chest Pain Center, Cath Lab, and other cardiovascular program recognitions).

• Coordinate preparation for regulatory surveys, audits, and accreditation reviews.

Data Analytics & Reporting

• Develop and maintain dashboards and reports on cardiovascular outcomes, volumes, and quality indicators.

• Translate complex clinical data into actionable insights for physicians, operational leaders, and executive leadership.

• Benchmark program performance against national registry data and peer institutions.

Program Collaboration

• Partner with physicians, nursing leadership, advanced practice providers, and operational teams to identify improvement opportunities.

• Support strategic initiatives aimed at improving access, care coordination, and patient outcomes across the cardiovascular service line.

Education & Culture of Quality

• Promote a culture of continuous quality improvement and data transparency within cardiovascular programs.

• Educate clinical teams on registry metrics, quality benchmarks, and performance improvement strategies.

Education

• Bachelor’s degree in Nursing, Health Information Management, Healthcare Administration, Public Health, or related field required.

• Master’s degree in healthcare administration, nursing, public health, or related field preferred.

Experience

• 5+ years of experience in healthcare quality, cardiovascular program management, or clinical registry oversight.

• Experience with cardiovascular registries such as American College of Cardiology NCDR or Society of Thoracic Surgeons STS preferred.

• Prior leadership or supervisory experience preferred.

Certifications (Preferred)

• Certified Professional in Healthcare Quality (CPHQ)

• Registered Health Information Administrator (RHIA) or related certification

• Clinical background (RN or allied health professional) desirable

• Quality improvement methodology (Lean, Six Sigma, or equivalent)

• Healthcare analytics and performance benchmarking

• Strong knowledge of cardiovascular clinical programs and workflows

• Leadership, collaboration, and change management

• Data visualization and reporting tools

• Regulatory and accreditation standards

• Registry data accuracy and submission timeliness

• Improvement in cardiovascular quality metrics and outcomes

• Successful accreditation and regulatory survey performance

• Engagement of clinical teams in quality initiatives

• Development of actionable performance reporting

If you'd like, I can also create a more advanced “service line leadership” version of this role (which many health systems now call Director of Cardiovascular Quality) that better aligns with large program growth, structural heart expansion, and regional CV networks—which seems relevant given the planning work you're doing around cardiology programs.

EDUCATION:

• BS (Required)

PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

LICENSES/CERTIFICATIONS:

• BLS - Basic Life Support - American Heart Association (AHA)American Heart Association (AHA)American Heart Association (AHA)

PAY RANGE: $75,000.00 - $115,000.00

The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, clinical licensure date, relevant qualifications, specialty, internal equity, location, and contracts.