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Manager – Clinical Quality

Traverse City, MI


Posted on August 2, 2018

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About Manager – Clinical Quality

SUMMARY The primary role of the Manager of Clinical Quality is to provide leadership for efforts to achieve outstanding performance on key metrics of quality and patient safety throughout Munson Medical Center via effective management of the team that supports organizational clinical quality improvement and medical staff peer review functions. Maintains a systems awareness and aligns goals and priorities with current and future organizational goals when advocating for quality Challenges and inspires self and others to seek quality goals above and beyond regulatory and accreditation mandates. Facilitates integration of key stakeholders into quality planning and work, fostering relationships across departments and disciplines that support patient-centeredness.


  • Graduate of an accredited School of Registered Nursing and currently registered in good standing with the State of Michigan, BA or BS degree in healthcare-related field required. Master’s degree in related field preferred.

  • A minimum of five years’ experience to include clinical nursing experience in an acute care setting. Additional three to five years experiences in medical staff peer review or healthcare quality/ performance improvement experience required.

  • Demonstrated experience with performance improvement methodologies.

  • Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest in field of expertise. Demonstrates an ongoing commitment to learn.

  • Maintenance of membership in a recognized professional organization preferred.

  • Possesses comprehensive knowledge of the clinical capabilities of Munson Medical Center as well as thorough knowledge of hospital organization and department functions.

  • Excellent interpersonal skills required. Demonstrated ability to communicate effectively with physicians, nurses, other health care professionals, Munson Medical Center staff at all levels, as well as the executive level and external customers. Ability to maintain a calm, professional demeanor under pressure.

  • Excellent verbal, written, and presentation skills are necessary. Computer database and word processing skills required.

  • Exceptional problem-solving skill. Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel and outside customers.

  • Requires independent judgment and action skills. Must maintain high level of confidentiality and ability to prioritize multiple tasks/activities. Strong organizational skills and the ability to concentrate while being subject to multiple interruptions and changing work priorities.

  • Self-directed; able to work effectively and efficiently with multiple interruptions and changing work priorities. Strong organizational and time management skills required. Able to make quality, independent decisions using analytical and problem solving skills. Demonstrates initiative and creativity in assigned work. Highly detailed and team oriented.

  • Demonstrated administrative and supervisory ability. Demonstrated ability to lead/direct others and to work effectively with persons of varied backgrounds, education, and experience. Facilitates organizational change, promotes professional and clinical advancement, and develops clinical and professional judgment through role modeling, teaching, coaching, and/or mentoring.

  • Demonstrates knowledge of confidentiality as it pertains to HIPAA and the handling of information sensitive to Munson Healthcare.

ORGANIZATION Reports to the Director of Organizational Quality and Patient Safety. Also has accountability to the System VP of Quality & Safety. Works in close collaboration with leaders across the organization, including the local Chief Medical Officer; Medical Staff Services; quality, safety and risk leaders; Infection Prevention Manager; and others. Also works cooperatively with system leaders of quality.

Age of Patients Served

No clinical contact


  1. Supports the Mission, Vision and Values of Munson Healthcare

  2. Embraces and supports the Performance Improvement philosophy of Munson Healthcare.

  3. Promotes personal and patient safety.

  4. Demonstrates effective customer service/interpersonal skills at all times. Applies techniques of problem solving, active listening, negotiation and strong consensus building skills. Employs a high level of tact and diplomacy when engaging internal and external resources and customers.

  5. Actively supports programs that strengthen a safety culture and create a safe environment for quality patient care.

  6. Participates in activities of various hospital, system, or medical staff committees, CQI teams/work groups to promote healthcare quality.

  7. Uses computer applications (Power Chart, Word, Excel, PowerPoint, Outlook, relevant regulatory applications, etc.) efficiently and effectively.

  8. Demonstrates initiative and judgment in adapting or devising solutions to meet unexpected or unusual conditions.

  9. Leads activities in support of promoting healthcare quality. Serves as a role model for patient quality and safety throughout the organization. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, the Corporate Compliance Program, Code of Ethics, SMDA, EMTALA, and patient safety, as well as other policies and procedures.

a. Assures organizational compliance with CMS and other regulatory reporting requirements related to quality and safety, including, but not limited to: CMS Inpatient Quality Reporting, CMS Outpatient Quality Reporting, Inpatient Psychiatric Facility Quality Reporting programs, electronic quality measures, National Database of Nursing Quality Indicators b. Communicates new regulatory requirements related to healthcare quality to appropriate administrators, physicians, and other health care professionals. Serves as a resource for the interpretation of these requirements, as well as reports distributed by these bodies. c. Leads coordination of data collection, analysis, and performance improvement efforts related to the BCBSM Clinical Quality Initiatives, CMS-required registries, MHA/HIIN, and other required or prioritized clinical quality initiatives d. Leads coordination of Medical Staff Peer Review and Ongoing Professional Performance Evaluation; leads coordination of support of quality efforts for specific Medical Staff departments and sections e. Works in collaboration with other appropriate staff and departments to coordinate education for compliance with regulatory standards related to quality.

  1. Leads and develops Clinical Quality team and manages department operations. Maintains professional growth and development; demonstrates an ongoing commitment to learn and encourages team members to do so as well.

a. Collaborates with VP, Director, and department members to develop and implement department goals and objectives (short-term and long-term) in concert with Munson Medical Center. b. Delegates to staff the authority necessary for the performance of their duties and ensures that adequate controls exist to render delegation effective. c. Assesses and coordinates work, setting or resetting priorities as determined by regulatory agencies and organizational priorities. d. Uses effective customer service/interpersonal skills at all times. Shares appropriate communications with staff in a timely manner. e. Monitors the job performance of staff in area of responsibility. Focuses on positive and constructive was to communicate, educate, solve conflict, and improve processes. f. As

Job at a Glance

About Munson Medical Center

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