The Chief Quality and Risk Management Officer (CQRMO) provides executive leadership and organizational oversight for Waterfall Community Health Center’s quality improvement, quality assurance, patient safety, clinical risk management, and performance improvement programs.

The CQRMO is responsible for developing and maintaining an integrated organizational approach to improving the quality and safety of care, identifying and mitigating clinical and operational risk, strengthening systems and processes, and promoting a culture of continuous improvement and patient safety.

The CQRMO serves as Waterfall’s designated leader for the Quality Improvement/Quality Assurance (QI/QA) program and health care risk management program and works closely with executive leadership, clinical leadership, operations, compliance, legal counsel, Human Resources, and the Board of Directors to ensure that quality and risk activities support Waterfall’s strategic priorities and applicable HRSA Health Center Program and Federal Tort Claims Act (FTCA) requirements.

Essential Duties and Responsibilities

Quality Improvement & Quality Assurance

• Provide executive oversight of Waterfall’s organization-wide QI/QA program and annual QI/QA Plan.

• Ensure implementation and ongoing evaluation of QI/QA policies, procedures, assessments, and improvement activities.

• Establish organizational quality goals, priorities, performance measures, and improvement strategies in collaboration with clinical and operational leadership.

• Monitor clinical quality, utilization, patient outcomes, patient experience, and other key performance indicators.

• Ensure QI/QA assessments are conducted at least quarterly and that findings result in appropriate improvement actions.

• Lead or oversee organizational performance improvement initiatives using recognized QI methodologies.

• Support clinical teams in improving performance on UDS, payer, value-based care, and other quality measures. 

• Oversee the organization’s patient complaint and grievance process, including monitoring trends, identifying systemic issues, and incorporating findings into quality improvement and patient safety activities.

• Monitor patient experience and satisfaction data and use findings to identify opportunities for improvement.

• Ensure organizational practices reflect current evidence-based clinical guidelines, standards of care, and standards of practice.

• Provide regular quality reports and recommendations to executive leadership, the Quality Improvement Committee, and Board of Directors.

Risk Management & Patient Safety

• Serve as Waterfall’s designated health care Risk Manager and oversee the organization’s health care risk management program.

• Maintain and annually update the organization’s Risk Management Plan and related policies and procedures.

• Conduct and document ongoing and periodic risk assessments and develop mitigation strategies based on identified risks.

• Oversee Waterfall’s incident/event reporting system and ensure appropriate triage, investigation, follow-up, corrective action, trending, and closure. Identify, analyze, and address adverse events, near misses, patient safety events, and other clinical risks.

• Lead or coordinate root cause analyses and other structured event reviews when appropriate.

• Monitor trends in incidents, claims, grievances, diagnostic and referral tracking, medication-related events, and other patient safety indicators.

• Promote a Just Culture and an environment that encourages timely reporting, learning, transparency, and continuous improvement.

• Ensure required annual risk management training is completed and maintain documentation supporting FTCA requirements.

• Coordinate annual and quarterly risk management reporting to executive leadership and the Board. Clinical Quality & Patient Safety Oversight

• Partner closely with the Chief Medical Officer/Medical Director and other clinical leaders to identify and address clinical quality and patient safety concerns. 

• Support provider peer review and other clinical quality assurance processes while maintaining appropriate confidentiality.

• Ensure effective systems are in place for tracking and following up on diagnostic tests, referrals, hospitalizations, emergency department visits, no-shows, and other high-risk clinical processes.

• Support development and implementation of corrective action plans arising from clinical investigations, patient safety events, audits, peer review, or identified quality concerns.

• Monitor implementation and effectiveness of corrective actions and escalate unresolved or significant risks to executive leadership.

Regulatory & FTCA Readiness

• Maintain organizational readiness related to HRSA QI/QA and FTCA risk management requirements.

• Partner with Compliance and other organizational leaders in preparation for HRSA Operational Site Visits, FTCA applications/site visits, audits, and other external reviews.

• Maintain documentation demonstrating implementation of Waterfall’s QI/QA and risk management programs.

• Track corrective actions resulting from external reviews related to quality, risk management, and patient safety through completion.

• Maintain awareness of evolving regulatory requirements and industry standards affecting quality, patient safety, and health care risk management.

Leadership & Governance

• Serve as a member of Waterfall’s Executive Leadership Team and provide an enterprise-level quality and risk perspective in organizational decision-making.

• Chair or provide executive leadership to the Quality Improvement and Risk Management Committees, as determined by organizational structure.

• Develop and present regular reports to the CEO, executive leadership, and Board regarding quality performance, patient safety, organizational risk, improvement activities, and emerging concerns.

• Develop annual departmental priorities, work plans, and budgets.

• Supervise and develop Quality and Risk Management staff and establish clear accountability for departmental responsibilities.

• Promote cross-functional collaboration among clinical, operational, compliance, HR, pharmacy, dental, behavioral health, and other departments.

• Foster an organizational culture in which quality and patient safety are shared responsibilities across all levels of the organization.

Minimum Qualifications

• Master’s degree in nursing, public health, health care administration, business administration, or a related field preferred.

• Current RN license strongly preferred; other clinical backgrounds may be considered based on experience.

• Minimum of five years of progressive experience in health care quality, patient safety, risk management, clinical operations, or related functions, including leadership responsibility.

• Knowledge of HRSA Health Center Program and FTCA requirements stronglypreferred.

• Experience leading organization-wide quality improvement and/or health care risk management programs.

• Demonstrated knowledge of quality improvement methodologies, patient safety principles, event investigation, root cause analysis, and corrective action.

• Experience working in an FQHC, community health center, ambulatory care environment, or other complex health care delivery organization strongly preferred.

Core Competencies

• Executive leadership and sound judgment

• Quality improvement and systems thinking

• Health care risk management and patient safety

• Clinical and operational credibility

• Data analysis and performance management

• Investigation and root cause analysis

• Change management

• Cross-functional collaboration

• Clear written and verbal communication

• Ability to appropriately escalate significant patient safety and organizational risks

• Ability to translate compliance and regulatory requirements into practical operational processes