Job Description

Full Time


The Director supports the development and implementation of quality improvement and risk management program at Sun Life Family Health Center, Inc. (hereafter "SLFHC") through coordinating and engaging in activities to proactively promote implementation of evidence based best practices, mitigate risk, and resolve deficiencies. The Director monitors, and manages quality improvement and risk management processes including those supporting compliance, regulatory and/or accreditation standards. Collects, analyzes and reports on a variety of data to assess the quality and appropriateness of care and treatment of patients and to provide oversight in the allocation and utilization of program resources.


  • Leads quality improvement efforts focusing on quality metrics and reporting;
  • Develops and implements metrics and performance targets in alignment with CMS, state licensing agencies, HRSA regulations and accreditation standards;
  • Coordinates quality improvement and risk management activities for accrediting, licensing, and certification surveys;
  • Utilizes quality assurance and quality improvement evaluation methodologies for measurement of protocol compliance and to sustain survey readiness, including ongoing preparedness reviews;
  • Analyzes data to determine trends and resource utilization for use in optimizing compliance and to prepare reports describing individual performance;
  • Supports SLFHC team with clinical audits and inspections, including, but not limited to, facilitation of inspection readiness, inspection management preparations and audit response support related to quality and risk management activities;
  • Assists in the education of providers in the importance of following guidelines and regulations in accordance CMS, state licensing agencies, HRSA regulations and accreditation standards;
  • Monitors cases to identify trends and emerging issues and presents to quality improvement and/or risk committees;
  • Works with SLFHC leaders, medical staff and providers to develop appropriate action plans to improve quality of health care delivery including participation in the peer review process;
  • Assists in the development of improvement plans with department/unit managers and supervisors in response to identified deficiencies;
  • Maintains documentation related to oversight including schedules/calendars of audits and monitoring activities, and electronic and/or paper copies of audits and follow-up activities;
  • Maintains quality and risk management departmental staff results by coaching and counseling as well as by properly planning, monitoring and appraising overall performance results;
  • Promotes excellence in internal and external customer service by maintaining consistent, timely communication regarding all facets of departmental activities with his/her co-workers;
  • Establishes/maintains good relationships with CEO, CMO, and department leaders to promote a cooperative and constructive environment for improvement;
  • Responsible for the oversight and completion of SLFHC's Clinical Quality measures and reporting to HRSA;
  • Coordinates Joint Commission activities such as ICM, FSA and monitors compliance with these activities, as applicable;
  • Coordinates Risk Management processes (incident reports, etc.) and provides the aggregated data to the Risk Management Committee;
  • Provides Risk Management training to the organization annually;
  • Conducts risk mitigation activities;
  • Demonstrates an understanding of facility organizational structure by utilization of appropriate channels of communication;
  • Provides reports to the SLFHC board of directors as required by the board calendar;
  • Ensures the quality improvement and risk management program and plans are reviewed and updated annually;
  • Collaborate with operations to maintain safety in the organization;
  • Collaborate with operations regarding SLFHC emergency preparedness.


  • Maintains professional credentials, and competencies including annual mandatory in-service requirements;
  • Implements Lean/Six Sigma methodologies, where applicable, to patient safety;
  • Other duties as may be assigned.
  • Conducts himself/herself in a manner consistent with the Mission and Vision statement of SLFHC
  • Upholds the Values of SLFHC in all day-to-day endeavors:
  • Integrity
  • Dignity
  • Excellence
  • Innovation
  • Empowerment
  • Stewardship
  • Education


  • Accountability- Role Model, mission, vision and shared values;
  • Customer Focus:
    Has a clear understanding of internal customers needs, preferences, timelines and decision-making criteria;
    Recognizes that building long-term customer satisfaction is the key to employee engagement;
  • Teamwork - If someone needs help, help them;
  • Initiative - Be innovative, apply fresh ideas and continuously improve how you do your work;
  • Confidentiality - Maintains strict confidentiality and respect the privacy of others;
  • Ethical -Demonstrate consideration and appreciation for co-workers and customer;
  • Respect - Demonstrate - consideration and appreciation for co-workers and customer;
  • Conflict Management. Can read situations quickly. Steps up to, and into, conflicts while seeing them as opportunities;
  • Dealing with Ambiguity. Thrives on situations involving risk and uncertainty, and anticipates the impact of change and directs self and others in smoothly shifting gears;
  • Communicates clearly and succinctly in both written and verbal form and adjusts the message to fit the audience (e.g. employees, management, community, Board of Directors, etc.);
  • Problem Solving. Requires interpersonal awareness, the ability to identify people’s wants and needs and to respond to each effectively. Uses logic to solve complex problems with effective solutions and looks beyond the obvious and does not stop after getting the initial answers.



  • Ability to gather data in an organized fashion from varied sources;
  • Ability to multitask and prioritize work;
  • Ability to organize data for dissemination, as applicable;
  • Excellent verbal and written communication skills required;
  • Flexibility and Adaptability;
  • Conduct daily duties in a professional manner.


  • Bachelors Degree required. Bachelors Degree in Public Health or Nursing preferred;
  • Minimum of five years work experience with considerable autonomy, self-direction and leadership;
  • Minimum of three years leadership experience leading autonomous teams;
  • Licensed in the State of AZ, or able to get licensed in the State of AZ;
  • Clinical background desired, Registered Nurse experience preferred;
  • Demonstrated successful track record for producing quality results.



[x] License: Registered Nurse or Licensed Practical Nurse


[x] 5 years experience in [x] addition to cert/degree;

[ ] in lieu of cert/degree

Specific Degree

[x] Degree: Bachelors. Bachelors Degree in Public Health or Nursing preferred.


[x] Bilingual (English-Spanish) helpful

[x] Computer literate

[x] Typing

[x] Filing procedures

[ ] Money handling

[x] Calculator, office machines, etc.

Physical demands

[ ] Balancing [x] Carrying [ ] Climbing

[ ] Crawling [ ] Crouching [x] Feeling

[x] Fingering [x] Grasping [ ] Kneeling

[x] Lifting 10 lbs. [ ] Pulling [x] Hearing (communicate)

[x] Talking (communicate) [x] Sitting [x] Standing (mobility)

[x] Walking (mobility) [x] Vision: far [x] Vision: near

[x] Vision: color [x] Vision: depth [x] Vision: (w/assistance)


[x] Airborne particles [ ] Muscular strain

[ ] Chemicals [ ] Caustics

[x] Electrical current [ ] Fumes

[x] Noise [x] Odors

[ ] Sharps [ ] Body fluids

The above statement reflects the general duties considered necessary to perform the principal functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the job.

Application Instructions

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