Quality Management Manager at AdventHealth

Date Posted: 1/26/2020

Job Snapshot

  • Job Schedule
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Wesley Chapel

Job Description


Quality Manager AdventHealth Wesley Chapel

Location Address: 2600 Bruce B. Downs Blvd Wesley Chapel, Florida 33544

Top Reasons to Work at AdventHealth Wesley Chapel

From state- of- the- art equipment to the most intricate building details, AdventHealth Wesley Chapel was designed from the ground up to maximize healing, patient care and wellness
Recognized as leader in patient satisfaction and was named Top 100 Hospital in Modern Healthcare Magazine by IBM Watson Health
50,000 sq ft community Health & Wellness Center
Comprehensive women’s health center named Inspiration Place that incorporates female physician specialists, women’s imaging, pelvic floor and female physical therapy and a boutique spa.
Consistently named a Top Workplace in Tampa Bay by the Tampa Bay Times
Opened an offsite 24 bed, 24/7 emergency room in Central Pasco to better serve the emergency health needs of residents in west and central Pasco



Work Hours/Shift:

FT Time/Days


  • Oversees the Quality Analysts, Stroke Coordinator, and Ortho-Neuro Coordinator (i.e. assignments, scheduling, daily operations, performance review, etc.);

  • Conduct orientation, evaluations, and assist with the hiring process of quality management staff

  • Oversees the policy and procedure process; develops and revises policies and procedures to comply with regulatory standards

  • Oversees Regulatory Compliance;

  • Oversees and coordinates the Quality Management Committee;

  • Responsible for maintaining and minimally performing an annual review and evaluation of the Quality Management Plan;

  • Serves as a member of hospital-wide committees as designated;

  • Oversees the abstraction of core measure data through validation of concurrent & closed record review, and direct observation to ensure the validation rate is above passing;

  • Assesses data collected to identify areas where improvements are needed, assists in and oversees the development of corrective action plans to improve performance and monitors results; Oversees that the documentation meets standards for reimbursement in relation to CMS guidelines and Value-Based Purchasing Program;

  • Develops, coordinates, implements, maintains, and oversees quality metrics education process for the Quality Analysts, Stroke Coordinator, Ortho-Neuro Coordinator, and other staff as applicable by cultivating and disseminating knowledge of best practice;

  • Oversees the Quality Analysts, Stroke Coordinator, and Ortho-Neuro Coordinator in their dissemination of any QM Program additions/updates to hospital staff and physicians in conjunction with department leaders and staff development department;

  • Oversees the Hospital’s Internal Audit Program;

  • Maintains up to date, accurate documentation of the QM Department tasks and projects to ensure the integration of information for use by the healthcare team;

  • Assists in strategic planning;

  • Provides feedback regarding data collected and outcomes to hospital leadership, medical staff, and others as applicable;

  • Facilitates and acts as a resource for survey readiness activities in compliance with regulatory & contractual requirements (DNV-GL, AHCA, CMS, Leapfrog, etc.);

  • Collaborates with hospital and medical staff leadership to identify the needs affecting the Quality Management System, oversees the implementation of corrective action(s) and subsequent evaluation of the effectiveness and sustainability of corrective action, and closure within defined timeframes;

  • Prepares departmental reports, studies and audits as needed;

  • Remains current and knowledgeable of all present and future mandates from accreditation/regulatory bodies including DNV-GL, ACHA, CMS, and other accrediting agencies as appropriate;

  • Other duties as assigned.


  • Position directly supervises a team of approximately 5-7 staff members. Serves as an internal consultant to the Leadership, Medical Staff, Nursing, and Ancillary Departments in matters pertaining to quality initiatives and regulatory/accreditation compliance. Position has the role of training and supervising others in group tasks and on an individual basis to ensure compliance with regulatory standards and performance improvement initiatives. Supervises the completion of tasks related to PI and regulatory compliance throughout the hospital.  Orients and trains new employees to hospital standards regarding PI and regulatory compliance.



  • Working knowledge of Federal, State, and Regulatory requirements in quality assessment performance improvement, resource management, hospital systems, accreditation, and licensure

  • Demonstrates strong professional, organizational, and interpersonal skills, emotional intelligence, diplomacy, tact, conflict management, delegation skills, and diversity awareness required for effective and creative leadership in working with all levels of the organization including physicians, committees, senior management, and trustees, as well as patients and their families.

  • Ability to lead, support, and build on current efforts of the Quality Management Systems and various other departments.

  • Ability to communicate effectively with outside agencies, third party payers, and regulators.

  • Ability to present information to both large and small groups.

  • Analysis & Critical Thinking: Strong problem solving, analysis, decision making, planning, and organizational skills

  • Foster team environment by overseeing and validating orientation and training to new team members

  • Communication: Effective communication skills (oral, written, presentation), is an active listener, and effectively provides balanced feedback.

  • Human Resources Management: Effectively hire, coach/develop staff, as well as manage resources, performance and employee relations, and supervise within established policies, procedures, and legislation.

  • Ability to interact with everyone in a considerate, helpful, and courteous manner.

  • Expresses appreciation to others for their work and treats others with respect.

  • Handle frequent interruptions; adapt to changes in workload and work schedule; establish priorities

  • Effectively manage time, conflicting priorities, self, stress, and professional development.

  • Proficient use of Microsoft Excel, PowerPoint, Word and computer operations.

  • Possesses extensive working knowledge of unit operations, patient care policies/procedures, and methods for obtaining and analyzing patient care data relevant to Performance Improvement.

  • Data graphing and data collection experience.

  • Ability to organize manage multiple projects simultaneously.

  • Ability to work and perform duties with minimum amount of supervision.

  • Accountable for the appropriate utilization of supplies and equipment.

  • Demonstrates initiative, flexibility, integrity, and diplomacy.

  • Ability to work with data that is of sensitive and confidential nature.


•         Working knowledge and experience in Cerner applications preferred


    • Registered Nurse graduated from an accredited school of nursing upon hire

    • Bachelor’s degree in healthcare-related field upon hire

    • Minimum five (5) years’ experience in an acute care setting with Lead, Clinical Coordinator, or Supervisor experience upon hire



  • Master’s degree in Nursing preferred


  • Current active and clear FL Registered Nurse license upon hire

  • 4 hours of Hip and Knee Replacement education within 6 months of hire date, then annually

  • Eight hours of Stroke education within 6 months of hire date, then annually

  • Current NIHSS certification upon hire, renewed as required


  • Certified Professional in Healthcare Quality (CPHQ) preferred

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Location | Organization | Category | Job Function