HCS Manager of Hospital Quality Reporting

Description

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well‑being of the unique communities we serve.

Summary

The HCS Manager of Hospital Quality Reporting is responsible for leading the strategy, operations, and performance oversight of publicly reported quality measures across the health system. This includes programs such as CMS Hospital Compare and Star ratings, Hospital Acquired Conditions, Value Based Purchasing, abstracted core measures, eCQMs, and other regulatory or payer‑based quality transparency initiatives. The Manager ensures timely, accurate, and complete data submission, as well as data‑driven quality improvement in performance areas tied to public reporting, reimbursement, and hospital reputation.

The Manager also stays current with proposed rule changes, new measures, methodology updates, data submission requirements, etc.

Reporting to the HCS Director of Hospital Quality Management, this position leads a team of highly skilled quality assurance specialists with expertise in EHR abstraction, chart review, and clinical metric interpretation. The Manager works closely with hospital quality leadership, clinical departments, and IT to translate evolving metric definitions into reliable workflows and ensure compliance with all regulatory requirements.

• Leading People – Leads people toward meeting the organization’s vision, mission, and goals. Ensures that departmental goals match those of the organization and that resources are allocated to meet priorities. Establishes an environment that creates incentives for, and eliminates barriers to, a team environment. Articulates common goals and communicates how individual roles contribute to team success.
• Leading Change – Proactively assesses the need for change and obtains resources to implement change initiatives. Communicates effectively and appropriately. Takes action to ensure that employees fully understand their roles, responsibilities and performance standards/expectations and provides ongoing feedback and support. Treats everyone in a manner that demonstrates fairness and consistency. Serves as a role model by demonstrating commitment to innovation and continuous improvement in organizational performance.
• Results Driven – Exceeds departmental and organizational goals and customer expectations. Participates in decision making that produce high‑quality results by applying knowledge, analyzing problems, and calculating risks. Consistently conveys that customers are the highest priority. Communicates in a manner that promotes and sustains customer satisfaction and encourages others to do the same. Understands the overall financial performance of the organization and applies financial concepts and practices to establish and maintain realistic budgets.
  
  Uses financial information to monitor budgetary responsibilities.
• Operational Management – Oversees daily operations and strategic direction for all health system quality reporting activities related to CMS (e.g., IQR, HACRP, HVBP), and other publicly reported programs. Manages, mentors, and develops a team of quality assurance specialists, ensuring accuracy, consistency, and excellence in data abstraction, interpretation, data submission, and reporting.
• Quality Reporting & System‑Wide Leadership – Ensures timely and accurate submission of all required data to external entities, meeting deadlines and minimizing risk of penalty or reputational harm. Serves as the health system’s subject matter expert on public quality measure definitions, risk adjustment methodologies, and abstraction criteria. Monitors and interprets changes in regulatory reporting requirements; collaborates with IT, clinical teams, and regulatory affairs to operationalize new or revised metrics.
  
  Facilitates regular reviews of performance trends and outliers; identifies opportunities for improvement and partners with frontline clinical teams and hospital leadership to drive corrective actions. Develops and maintains internal audits and quality assurance processes to ensure ongoing abstraction reliability and adherence to program rules.…