Manager of Quality, Compliance, and Risk

Manager of Quality, Compliance, and Risk

Reports To: Associate Medical Director

Supervises: N/A

Location: Caroline Street Clinic

Overview
The Manager of Quality, Compliance, and Risk leads Healthcare for the Homeless – Houston (HHH)’s organizational strategy to ensure safe, high-quality, and compliant care for people experiencing homelessness. This role oversees quality assurance and performance improvement (QAPI) initiatives, regulatory and accreditation compliance, incident and risk management, and serves as the EPIC EHR optimization lead for clinical quality workflows and data reporting.

This position works at the intersection of compliance, care delivery, technology, and continuous improvement. The manager develops and manages organizational systems that ensure compliance with HRSA Health Center Program expectations, HIPAA, FTCA, UDS, OSHA, and other relevant standards. They serve as a collaborative partner to clinical, operations, finance, and IT teams—helping align frontline practices with strategic priorities and ensuring performance is tracked, reported, and used to guide improvement.

Duties and Responsibilities

Compliance & Regulatory Oversight

• Serve as the organizational lead for HRSA Operational Site Visit (OSV) readiness, FTCA deeming and re-deeming applications, HIPAA and OSHA compliance, and other regulatory audits.
• Maintain and update policies and procedures to align with evolving compliance requirements.
• Conduct regular internal reviews and mock audits to assess compliance readiness across departments.
• Coordinate response to regulatory incidents, complaints, and investigations, including root cause analyses, documentation, and corrective action planning.
• Support mandatory training for staff on compliance topics (e.g., HIPAA, incident reporting, patient rights, infection control).

Quality Assurance & Performance Improvement (QAPI)

• Develop internal dashboards to monitor quality measures including UDS, HEDIS, and patient experience metrics.
• Partner with clinical leaders to implement workflows that support timely, complete documentation of clinical services and screenings.
• Conduct internal audits and chart reviews to assess clinical documentation and identify training or process improvement needs.
• Track and report clinical outcomes and key indicators across departments, helping identify trends, gaps, and improvement strategies.

Risk Management and Incident Response

• Oversee organizational risk management systems including incident reporting, root cause analysis, and corrective action planning.
• Track incident trends and near misses; support department leads in developing sustainable improvements that reduce patient and organizational risk.
• Collaborate with legal counsel and insurance carriers on incident response and documentation.

Data and Reporting

• Serve as the primary liaison between HHH and Epic/IT teams related to quality, documentation, and compliance workflows.
• Coordinate build requests, clinical decision support tools, and Epic reporting dashboards to support quality initiatives.
• Validate, analyze, and submit Uniform Data System (UDS) and other quality data reports in coordination with clinical and finance teams.
• Ensure alignment between clinical workflows, EHR documentation, and reporting requirements to maximize data accuracy and utility.
• Partner with development and finance teams to ensure timely, compliant reporting on public grants, including HRSA, HHS, and local government contracts.
• Use population health data to identify service gaps, monitor disparities, and guide programmatic adjustments.

Cross-Departmental Collaboration and Systems Leadership

• Collaborate with the Manager of Integrated Care, Chief Medical Officer, and billing/finance leaders to align performance standards across clinical operations, revenue cycle, and documentation practices.
• Serve as staff liaison to the Board of Directors Health Quality Committee, preparing and presenting performance data and compliance updates.

Support HHH Mission

• Demonstrates a commitment to HHH’s mission of promoting health, hope, and dignity for individuals experiencing homelessness through equitable and compassionate care.
• Upholds trauma-informed, culturally responsive, and patient-centered principles in all interactions, contributing to an inclusive and supportive environment for patients and team members.
• Actively contributes to a culture of collaboration, accountability, and innovation in service of our goal to eliminate health disparities and advance systems-level change.

Minimum Qualifications

• Bachelor’s degree in Healthcare Administration, Public Health, Nursing, or related field.
• 7+ years of experience in healthcare quality and compliance

Preferred Qualifications

• Master’s degree and prior work in an FQHC or regulatory-heavy environment.
• Deep understanding of UDS, FTCA, HIPAA, QI methodologies, and CMS/HRSA reporting standards.
• Familiarity with population health data, EHRs, and risk management frameworks.
• HHH values lived experience as an essential form of expertise. Individuals who have experienced homelessness, housing instability, or other barriers to healthcare access are strongly encouraged to apply.