QUALITY & PERFORMANCE IMPROVEMENT MANAGER

Reports to: Chief Clinical Services Officer

Hourly Range: $30.00 - $45.00 per hour

Wage dependent upon education, experience, and qualifications.

Job Description Summary

The Quality & Performance Improvement (QAPI) Manager plans, organizes, coordinates, and leads Heartlinks' Quality Assessment and Performance Improvement (QAPI) program while supporting organization-wide performance improvement initiatives. This position works collaboratively with leadership and all departments to promote a culture of continuous quality improvement, regulatory compliance, patient safety, and operational excellence.

This is a unique opportunity to lead the continued evolution of Heartlinks' quality and performance improvement program, partnering directly with executive leadership to strengthen organizational processes, regulatory readiness, data-driven decision-making, and a culture of continuous improvement across all service lines.

The QAPI Manager utilizes data analysis, process improvement methodologies, and interdisciplinary collaboration to identify opportunities for improvement, implement sustainable solutions, and ensure compliance with federal, state, and organizational standards. This position serves as a resource for quality initiatives across hospice, palliative care, community programs, adult family home operations, and administrative departments.

Essential Job Functions and Responsibilities

• Coordinates and maintains the organization's Quality Assessment and Performance Improvement (QAPI) program in accordance with CMS Conditions of Participation and organizational goals.
• Facilitates monthly QAPI committee meetings, prepares agendas, records minutes, and tracks action items through completion.
• Collects, analyzes, trends, and reports quality metrics, patient outcomes, satisfaction data, operational indicators, and regulatory measures.
• Develops dashboards and reports to assist leadership in monitoring organizational performance and strategic initiatives.
• Coordinates performance improvement projects using evidence-based quality improvement methodologies, including Plan-Do-Study-Act (PDSA) cycles and root cause analysis.
• Identifies trends and opportunities for improvement through review of incident reports, complaints, audits, surveys, and quality data.
• Collaborates with department leaders to establish measurable goals, monitor outcomes, and implement corrective actions when needed.
• Assists in preparation for state surveys, accreditation reviews, and regulatory audits by ensuring documentation and quality processes remain survey ready.
• Coordinates follow-up and monitoring of corrective action plans resulting from audits, surveys, or quality reviews.
• Maintains organization-wide policy review schedules and document control processes in collaboration with leadership.
• Assists with development, implementation, and evaluation of organizational policies, procedures, and standardized workflows.
• Supports strategic planning initiatives through data collection, project coordination, and outcome measurement.
• Provides education and resources to staff regarding quality improvement principles, regulatory requirements, and organizational performance initiatives.
• Promotes a culture of continuous learning, accountability, transparency, and excellence throughout the organization.
• Performs other duties as assigned to support organizational quality and performance improvement efforts.

Position Qualifications

• Bachelor's degree in Healthcare Administration, Nursing, Public Health, Business Administration, Quality Management, or related field or equivalent combination of education and experience preferred.
• Minimum of three years of experience in healthcare quality improvement, compliance, project management, healthcare operations, or a related field preferred.
• Hospice, home health, post-acute care, or community-based healthcare experience strongly preferred.
• Knowledge of CMS Conditions of Participation, quality improvement principles, accreditation standards, and regulatory compliance requirements preferred.
• Experience with quality improvement methodologies such as PDSA, Lean, Six Sigma, or root cause analysis preferred.
• Certification such as Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma, Project Management Professional (PMP), or similar is preferred but not required.
• Demonstrated ability to collect, analyze, interpret, and present data to support organizational decision-making.
• Strong project management, organizational, and time management skills with the ability to independently manage multiple priorities.
• Excellent written, verbal, and interpersonal communication skills with the ability to collaborate effectively across departments and disciplines.
• Proficiency in Microsoft Office applications and electronic health record or quality reporting systems.
• Self-directed with the ability to work independently while fostering strong collaborative relationships.
• Ability to maintain confidentiality and exercise sound judgment in handling sensitive organizational information.

Physical Requirements

• Prolonged periods of sitting while working at a computer.
• Frequent standing, walking, bending, and reaching throughout the workday.
• Ability to occasionally lift and carry up to 25 pounds.
• Must possess a valid driver's license, maintain an insurable driving record, and have reliable transportation to travel throughout Heartlinks' service area as needed.
• Visual acuity and hearing sufficient to perform required job duties.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of this position.

Benefits

• Full-time employees accrue up to 168 hours of paid time off annually, in addition to Washington State paid sick leave accrued at the rate of one hour for every 40 hours worked. Bereavement leave and jury duty leave are also available.
• Medical, dental, vision, and life insurance benefits are available. Heartlinks pays 100% of employee medical premiums and 75% of employee dental and vision premiums. Benefits begin the first day of the month following employment.
• Mileage reimbursement for approved business travel.
• Holiday pay for six observed holidays.
• Eligibility to participate in the 401(k) retirement plan upon hire. Heartlinks provides a dollar-for-dollar employer match up to 5% of eligible earnings after one year of employment and completion of 1,080 hours worked.
• Tuition reimbursement and professional development assistance.
• Support for quality improvement education and professional certifications.

Equal Employment Opportunity

Heartlinks is an Equal Opportunity Employer and is committed to creating an inclusive workplace where all employees are valued and respected. Employment decisions are made without regard to race, color, religion, creed, sex, pregnancy, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, genetic information, or any other status protected by applicable federal, state, or local law.

Disclaimer

This job description is intended to describe the general nature and level of work performed by individuals assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications. Heartlinks reserves the right to modify this job description at any time to meet organizational needs.