POSITION SUMMARY
The Healthcare Quality Specialist supports Rocky Boy Health Center’s organization-wide Quality Assurance and Performance Improvement (QAPI), accreditation, patient safety, risk management, professional peer review, and infection prevention activities. Working under the direction of the Quality Director, this position monitors organizational performance, conducts audits and tracers, supports performance and process initiatives, assists with incident review and procedural development, and helps maintain continuous readiness for AAAHC accreditation and other applicable healthcare requirements.

As part of the Quality Department, the Healthcare Quality Specialist also supports RBHC’s Infection Prevention and Control Program through surveillance, monitoring, auditing, staff education, policy review, and implementation of infection prevention practices across the organization.

This position works collaboratively with clinical and operational departments to identify process and operational opportunities, implement changes, measure outcomes, and promote a culture of patient safety, accountability, and continuous improvement. This is an on-site position and is not eligible for remote work.

KEY RESPONSIBILITIES
Quality Assurance & Performance Improvement

• Support RBHC’s organization-wide Quality Assurance and Performance Improvement (QAPI) program.
• Conduct clinical, operational, documentation, and compliance audits and tracers to evaluate adherence to organizational policies and applicable standards.
• Collect, analyze, and report quality and performance data to identify trends, risks, and opportunities for improvement.
• Assist departments with development and implementation of performance and process initiatives, including establishing measures, monitoring progress, and evaluating outcomes.
• Facilitate or participate in root cause analyses, procedural planning and follow-up monitoring.
• Develop dashboards, reports, and other tools to communicate quality performance to leadership, committees, and departments.
• Monitor the completion and effectiveness of process changes resulting from audits, incidents, complaints, accreditation findings, and other quality activities.

Accreditation & Regulatory Readiness

• Support continuous readiness for AAAHC accreditation and other applicable healthcare requirements.
• Conduct tracers, mock surveys, documentation reviews, and other accreditation readiness activities.
• Assist departments in interpreting standards, identifying operational gaps, and developing processes.
• Maintain documentation and evidence necessary to demonstrate compliance with accreditation standards.
• Review organizational policies, procedures, and practices for alignment with accreditation and regulatory requirements.

Patient Safety & Risk Management

• Monitor incidents, adverse events, near misses, and other patient safety concerns through Healthicity and other reporting mechanisms.
• Assist with the investigation, analysis, response, planning, and follow-up of reported events.
• Identify trends in patient safety and risk data and communicate significant findings to appropriate leadership and committees.
• Promote organizational reporting and a culture focused on learning, prevention, and operational excellence.

Infection Prevention & Control

• Support implementation and ongoing operation of RBHC’s Infection Prevention and Control Program.
• Conduct infection prevention surveillance, audits, tracers, and environmental rounds throughout clinical and support areas.
• Monitor adherence to infection prevention practices, including hand hygiene, standard precautions, transmission-based precautions, environmental cleaning, and other applicable protocols.
• Assist with investigation and follow-up of potential healthcare-associated infections, exposures, outbreaks, and other infection prevention concerns.
• Develop and provide staff education on infection prevention and control practices.
• Review infection prevention policies and procedures and assist with updates based on current evidence, organizational needs, and applicable CDC, OSHA, IHS, AAAHC, and other requirements.
• Collaborate with Pharmacy, Laboratory, medical staff, and other departments on antibiotic stewardship and infection prevention initiatives.
• Support employee health activities related to infection prevention, including exposure management, immunization monitoring, TB screening, and vaccination compliance.
• Integrate infection prevention considerations into emergency preparedness planning, policies, and exercises.

Quality Systems & Organizational Support

• Serve as administrator for the Stat system and support effective use of real-time location, patient flow, alert, and workflow data.
• Analyze Stat and other operational data to identify opportunities to improve patient flow, efficiency, safety, and patient experience.
• Participate in or support Quality, Risk Management, Infection Control, Safety, Emergency Preparedness, and other organizational committees as assigned.
• Provide quality improvement education, technical assistance, and support to departments throughout RBHC.
• Perform other duties related to quality, accreditation, patient safety, risk management, and infection prevention as assigned.

Peer Review & Clinical Quality

• Coordinate and support RBHC’s ongoing professional peer review process in accordance with organizational policy, medical staff requirements, and applicable accreditation standards.
• Identify cases for peer review based on established criteria, quality indicators, adverse events, complaints, referrals, and other clinical quality considerations.
• Coordinate case preparation and distribution of appropriate documentation for peer review while maintaining required confidentiality and protections.
• Track peer review cases, findings, recommendations, procedural updates, and follow-up through completion.
• Maintain peer review records and documentation in accordance with organizational policy, confidentiality requirements, and applicable peer review protections.
• Assist the Medical Director, Medical Executive Committee, Quality Director, and other designated reviewers with scheduling and administration of peer review activities.
• Monitor peer review trends and aggregate findings to identify potential system-level opportunities for process refinement, education, or patient safety interventions.
• Ensure appropriate findings and recommendations are routed to responsible leadership or committees for follow-up while maintaining separation of confidential peer review information as required.
• Assist with development and maintenance of peer review policies, procedures, review criteria, forms, tracking systems, and processes.
• Support integration of peer review findings, when appropriate, into RBHC’s broader Quality Assurance and Performance Improvement activities.
• Coordinate with Credentialing and Medical Staff functions when peer review information is relevant to ongoing professional practice evaluation, reappointment, privileging, or other provider quality processes, consistent with applicable policies and confidentiality requirements.

MINIMUM QUALIFICATIONS

• Associate’s degree in healthcare administration, public health, nursing, allied health, health information management, business administration, or a related field.
• Two years of experience in a healthcare setting, preferably involving quality improvement, accreditation, patient safety, infection prevention, compliance, risk management, healthcare operations, or related function.
• Demonstrated ability to conduct audits, evaluate processes, identify deficiencies, and assist with development and implementation of corrective actions.
• Ability to collect, analyze, interpret, and communicate quality and performance data.
• Strong organizational and project management skills, including the ability to manage multiple priorities, deadlines, and follow-up activities.
• Strong written and verbal communication skills and the ability to work effectively with clinical staff, department managers, and organizational leadership.
• Proficiency with electronic systems, spreadsheets, data tracking, and reporting tools.
• Ability and willingness to obtain training and develop competency in healthcare quality improvement, accreditation, patient safety, and infection prevention.

DESIRED QUALIFICATIONS

• Bachelor’s degree in healthcare administration, public health, nursing, allied health, health information management, quality management, or a related field.
• Current licensure or certification as a healthcare professional, such as Registered Nurse, Licensed Practical Nurse, Medical Laboratory Scientist/Technician, Respiratory Therapist, or other allied health professional.
• Experience with healthcare accreditation, particularly AAAHC.
• Experience with healthcare Quality Assurance and Performance Improvement (QAPI) programs.
• Experience in infection prevention and control, including surveillance, auditing, staff education, or exposure management.
• Experience conducting tracers, root cause analyses, corrective action plans, or performance improvement projects.
• Experience with Healthicity, Stat.io, Epic, or similar healthcare quality, safety, clinical, or data systems.
• Certified Professional in Healthcare Quality (CPHQ), Certified in Infection Control (CIC), Certified Professional in Patient Safety (CPPS), or similar credential, or willingness to pursue applicable certification.
• Training in Root Cause Analysis, Plan-Do-Study-Act (PDSA), or other performance improvement methodologies.
• Experience working in tribal, IHS, ambulatory, FQHC, or rural healthcare settings.
• Experience coordinating or supporting medical staff peer review, provider performance evaluation, credentialing quality activities, or other clinical quality review processes.

Please note that all communication will be via e-mail.

Disclaimer

This employment announcement does not contain a comprehensive description of activities, duties, or responsibilities that are required for this position. Duties, responsibilities, and activities will be reviewed periodically as duties and responsibilities change with necessity. Applicants with credentials that do not meet the minimum qualification for this position will not be considered. Rocky Boy Health Center Human Resources disclaims responsibility for ensuring the completion of application packages, considering only those applications received in proper and completed form before the 4:00 PM closing date for the advertised position. This employment announcement is subject to change depending on budget availability and organizational priorities. Employment offers are contingent upon the satisfactory completion of a background check and pre-employment drug test, with successful applicants being subject to a 60 business day probationary period.

Notice to Recruiting Agencies and Third-Party Vendors

Rocky Boy Health Center does not accept unsolicited resumes, proposals, or candidate submissions from recruiting agencies or third-party vendors. We are not seeking new recruiting or placement services for any positions at this time. Any unsolicited submissions will be considered property of Rocky Boy Health Center, and we will not be responsible for any associated fees.