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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 position is responsible for directing Hospital Quality Management services in support of UNC Health’s Unified Quality strategy. This leader coordinates activities of three shared services functions (Hospital Quality Improvement Support, Hospital Quality Reporting, and National Registry Participation) to support owned and managed hospitals in providing safe, effective, highly reliable care exceeding national median benchmarks.

Reporting to the Executive Director of Hospital Quality and Care Redesign, the Director of Hospital Quality Management is responsible for managing multiple projects simultaneously ensuring consistency with UNC HCS Quality strategy, commitments and goals. This includes day to day management of a team responsible for these efforts and also includes financial oversight, and resource allocation for these strategic initiatives. The Director serves as a collaborative resource for leaders in the Academic and Community Quality Improvement teams to provide full-cycle feedback, best practice sharing, and support for ongoing quality improvement across the health system.

**Responsibilities** :

**Leading People** – Direct and mentor a multidisciplinary team across Hospital Quality Improvement Support, Hospital Quality Reporting, and National Registry Participation to achieve UNC Health’s Unified Quality strategy. Foster an inclusive environment that encourages collaboration among system-wide hospital CMOs, quality teams, and Academic/Community Quality Improvement leaders. Clearly delegate responsibilities—such as overseeing data collection for mortality reduction projects or coordinating readiness assessments for Leapfrog surveys—set measurable performance expectations, and hold team members accountable for delivering safe, effective, and highly reliable care that exceeds national median benchmarks. Provide ongoing coaching and professional development to elevate staff expertise in best practices, data analytics, and regulatory requirements.

**Leading Change** – Spearhead the design, communication, and implementation of hospital-wide quality improvement initiatives in priority areas (e.g., reducing patient harm, improving transitions of care, and lowering readmission rates). Articulate a compelling vision for each change effort— such as launching a system-wide sepsis mortality reduction protocol— by engaging key stakeholders (CMOs, nurse leaders, quality managers, and vendor partners such as Vizient). Identify and remove barriers (e.g., data silos or resource limitations) by securing necessary tools, staffing, and funding, and model commitment to innovation by piloting new reporting technologies or registry processes. Provide transparent, frequent updates on progress, challenges, and next steps to ensure buy-in and sustained momentum.

**Results Driven** – Translate UNC HCS Quality goals into actionable, measurable outcomes by applying clinical and operational expertise to complex problems (e.g., analyzing root causes of elevated readmission rates or benchmarking hospital-acquired condition performance against national medians). Make data-informed decisions—such as reallocating resources to hospitals underperforming on 30-day mortality metrics—and hold yourself and others accountable for delivering timely, cost-effective results. Oversee the development and maintenance of publicly reported quality metrics (e.g., Vizient, Leapfrog, CMS 5-Star Rating, specialty registry benchmarks, and US News Hospital Rankings), ensuring accuracy, completeness, and on-time submission. Cultivate a culture of continuous improvement by sharing best practices across owned and managed hospitals and promptly addressing any performance gaps identified in external benchmarking reports.

**Financial Focus** – Lead financial planning and oversight for all hospital quality management activities, including budgeting for internal quality improvement projects and allocating resources for registry participation fees, reporting software, and external vendor consulting (e.g., Leapfrog or Vizient contracts). Develop strategic financial models that optimize performance in CMS and commercial payer programs at risk (Meaningful Use, Value-Based Purchasing, Readmission Reduction, and Hospital Acquired Conditions), ensuring hospital teams understand the financial impact of quality initiatives. Provide detailed cost–benefit analyses and regular reports to senior leadership on return on investment for key programs—such as the projected savings from improved Vizient ratings— and proactively identify opportunities to reallocate funds or secure grant support to enhance quality outcomes.

Other Information

Other information:

Education Requirements:

• Bachelor’s degree required. Master’s Degree with administrative focus (MHA, MBA, etc) preferred.

Licensure/Certification Requirements:

• No licensure or certification requirements.

• Prior clinical experience (Nursing, PT/OT/SLP, etc) preferred.

• Healthcare Quality certification (Lean Six Sigma, CPHQ, IHI, etc) or Project Management Certification (e.g., PMP) preferred

Professional Experience Requirements:

• Seven (7) years of related experience, with at least five (5) years of management experience in quality, project management, and data analysis.

Knowledge/Skills/and Abilities Requirements:

Job Details

Legal Employer: STATE

Entity: Shared Services

Organization Unit: Hospital Quality & Innovation

Work Type: Full Time

Standard Hours Per Week: 40.00

Pay offers are determined by experience and internal equity

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: US:NC:Morrisville

Exempt From Overtime: Exempt: Yes

This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Health Care System, in a department that provides shared services to operations across UNC Health Care; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job.

Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email [email protected] if you need a reasonable accommodation to search and/or to apply for a career opportunity.

Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.