The posting
Job Title: Area Safety and Quality Officer
Location: Modesto, CA, US (100% Onsite for rounding across two hospitals)
Position Type: Regular, Full-Time | Travel: Up to 20%
Job Level: Director / Senior Director
Salary Range: USD $216,700 – $255,000 / year
Travel Requirements: Up to 20% of the time (local service area rounding).
Visa Sponsorship: Not available for this position
Relocation: Evaluated on a case-by-case basis.
Position Overview
The Area Safety and Quality Officer provides strategic leadership, executive oversight, and clinical expertise across small- to medium-sized service areas (facilities with under 300 licensed beds). Responsible for two hospitals within the Modesto service area, this role drives the development and execution of comprehensive clinical quality, patient safety, infection prevention, risk management, and continuous survey readiness initiatives.
The ideal candidate is a seasoned Registered Nurse with executive-level experience leading a health system Quality Department, adept at aligning clinical operations with regulatory standards, evidence-based practices, and organizational strategy.
Key Responsibilities
Strategic Leadership & Operational Management
- Build organizational capacity and prepare high potentials for growth opportunities and advancement; build collaborative networks inside and outside the organization.
- Provide a framework for soliciting and acting on performance feedback; drive collaboration to set goals and provide open feedback and coaching to foster performance improvement.
- Model and drive continuous learning, overseeing the recruitment, selection, and development of talent; stay current with industry trends, benchmarks, and best practices.
- Act as a thought leader on industry trends, benchmarks, and best practices; share insights within and across teams to drive continuous improvement.
- Motivate and empower teams; maintain a highly skilled and engaged workforce by aligning cross-functional resource plans with business objectives.
- Provide guidance on complex decisions and create opportunities for expanded decision-making scope and impact across teams.
- Oversee the operation of multiple units and/or departments by identifying member and operational needs; translate business strategy into actionable requirements.
- Engage strategic, cross-functional business units to champion and drive support for business plans and priorities; set standards, measure progress, and ensure resolution of escalated issues.
- Set and communicate goals and objectives; analyze resources, costs, and forecasts to incorporate into business plans; obtain and distribute necessary resources.
- Anticipate and remove performance obstacles; address performance gaps and implement contingency plans to ensure business objectives are accomplished.
- Serve as a subject-matter expert and trusted source to executive leadership, offering influence and consultation in the development of broader organizational strategy.
Clinical Quality, Safety & Program Development
- Serve as the subject matter expert on clinical quality improvement processes and regulations for internal/external executive stakeholders, sponsors, business owners, and external quality organizations.
- Provide consultation on the interpretation and implementation of policies, regulations, and legislation, advising on long-term strategies to address changing regulatory environments.
- Proactively engage internal and external committees and projects to determine necessary infrastructure changes to advance quality assurance initiatives and ensure long-term compliance.
- Foster collaborative, results-oriented partnerships across clinical and administrative roles to influence organizational policy and maintain an adaptive compliance framework.
- Forecast and direct future educational programs to raise awareness of changing regulation requirements, internal concerns, and database usage.
- Identify and remove barriers to process improvement, weighing practical, technical, and organizational capability considerations when advising on policy changes.
- Oversee the development of new clinical quality improvement programs by maintaining key stakeholder relationships and ensuring program sustainability.
- Serve as an SME across health concepts, regulatory requirements, and change management principles to prioritize programs that optimize clinical quality, safety, and health outcomes.
- Advocate for clinical programs and consult with executive management, technology stakeholders, and external vendors to develop the health system as a learning organization.
Grievance, Quality of Care Reviews & Surveillance
- Direct the quality-of-care complaints and review process, representing the organization in grievance meetings, cases, reviews, referrals, and formal mechanisms.
- Respond to and direct the preparation of documentation, records, and information requested for specific and highly sensitive patient case reviews.
- Report trends in investigations and claims for red flags, appeal reasons, and overturns, advising leadership on strategic direction to reduce reoccurrences.
- Define standards for the surveillance of quality improvement metrics, quality care incidents, and near misses according to established protocols to ensure consistent application of policies.
Infection Prevention & Control
- Oversee infection prevention and control programs to improve employee and patient safety by presenting information from epidemiological investigations, simulations, and cluster research to executive stakeholders.
- Serve as the primary contact during significant outbreak containment protocols and response efforts.
- Consult with Administration on the infection control implications of architectural design, renovation, and facility construction.
Risk Management & Patient Safety
- Direct risk management efforts by defining and presenting standards for corrective action plans identified through utilization reviews, clinical audits, claim denials, and satisfaction surveys.
- Utilize information gathered from root cause analysis (RCA), failure mode and effect analysis (FMEA), and adverse event assessments to establish policies that mitigate future risk.
- Define standards for health outcome analysis to continuously monitor oversight effectiveness.
- Oversee patient safety programs by serving as the primary contact during significant event management and response to safety hazards, accidents, incidents, and threats.
- Collaborate with executive management and external personnel to develop patient care and satisfaction programs that improve patient flow, clinical support, and transitions of care.
Data Management & Performance Improvement
- Oversee systems, procedures, and forms to improve data management programs, using data to monitor and improve worker and patient safety programs.
- Ensure the organization's quality improvement monitoring agenda integrates data management, pattern analysis, and practice trends into long-term strategic plans.
- Act as an SME in interpreting and applying data from databases, vital statistics, discharge records, claims, and health sources to guide long-term strategy.
- Present and advise on the application of formatted reports (e.g., infection control research, utilization reviews, population health needs analysis) to guide executive planning.
Regulatory Audits & Continuous Survey Readiness
- Direct regulatory audits and survey efforts, serving as the primary liaison between government, regulatory bodies, and management during onsite visits and evaluations.
- Establish long-term standards for audit documentation, information, tools, and reporting throughout the auditing process.
- Forecast and establish continuous survey readiness activities to adapt to evolving regulatory requirements.
Care Optimization & Population Health
- Define the future direction and standards for evaluating the cost-effectiveness, practicality, and appropriateness of medical care provided to patients.
- Ensure case reviews are completed and followed up on, partnering with stakeholders to empower practitioners to adhere to standard operating procedures for timely care access.
- Advocate with key stakeholders to resolve systemic concerns and ensure treatment plans meet patient needs promptly.
- Define standards for population health needs to drive policy direction addressing community health concerns, transportation access, patient rights awareness, and no-show reductions.
- Utilize patient case review results to advocate for policy and technology changes that improve overall health care utilization.
Qualifications & Requirements
Must-Have Requirements:
- Active Registered Nurse (RN) License.
- Executive Quality Leadership: Proven experience leading a Quality Department at the Director level or above.
- Inpatient Experience: Extensive clinical and operational leadership experience in an inpatient hospital setting.
- Onsite Availability: 100% onsite presence required for daily rounding across two hospital facilities in the Modesto service area.
Education & Experience:
- Education: Master’s degree in Business, Health Care Administration, Public Administration, or a directly related field.
- Total Healthcare Experience: Minimum 10 years of progressive experience in clinical and management roles within a health plan or multi-faceted healthcare system/multi-provider setting.
- Leadership: Minimum 9 years in a leadership role (with or without direct reports).
- Clinical & Administrative Background: Minimum 8 years in a clinical setting, healthcare administration, or directly related field.
- Budgeting & Operations: Minimum 4 years of experience managing operational or project budgets.
- Data & Systems: Minimum 6 years of experience utilizing databases and spreadsheets for data analysis.
- Training: Minimum 4 years of experience delivering professional training programs.
- General Health System Experience: Minimum 7 years in healthcare or a directly related field (combined with Master's degree).
Certifications:
- Professional Healthcare Quality Certificate (e.g., CPHQ): Must be obtained within 24 months of hire.
