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Description

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**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, Leapfrog, Vizient, 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.

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.

**Responsibilities** :

**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** - Oversee daily operations and strategic direction for all health system quality reporting activities related to CMS (e.g., IQR, HACRP, HVBP), Leapfrog, Vizient, and similar programs. Manage, mentor, and develop a team of quality assurance specialists, ensuring accuracy, consistency, and excellence in data abstraction, reporting, and interpretation.

**Quality Reporting & System-Wide Leadership-** Ensure timely and accurate submission of all required data to external entities, meeting deadlines and minimizing risk of penalty or reputational harm. Serve as the health system’s subject matter expert on public quality measure definitions, risk adjustment methodologies, and abstraction criteria. Monitor and interpret changes in regulatory reporting requirements; collaborate with IT, clinical teams, and regulatory affairs to operationalize new or revised metrics. Facilitate regular reviews of performance trends and outliers; identify opportunities for improvement and partner with frontline clinical teams and hospital leadership to drive corrective actions. Develop and maintain internal audits and quality assurance processes to ensure ongoing abstraction reliability and adherence to program rules. Represent Hospital Quality Management in system-wide meetings and workgroups related to publicly reported measures, performance improvement, data governance, and regulatory compliance. Support transparency and stakeholder understanding of health system performance through dashboards, reports, and educational presentations

Other Information

Other information:

Education Requirements:

• Bachelor’s degree in Nursing, Health Information Management, Public Health, or a related clinical/healthcare field.

• Preferred: Master’s degree in Healthcare Administration, Public Health, or related field

Licensure/Certification Requirements:

• Preferred: Certification in Healthcare Quality (e.g., CPHQ)

Professional Experience Requirements:

• Minimum 5 years of experience in quality reporting or clinical quality improvement in a hospital or health system setting

• At least 2 years of people leadership or team management experience

• Preferred: Experience managing abstraction or data submission software platforms (e.g., Vizient and Leapfrog portals)

Knowledge/Skills/and Abilities Requirements:

• Deep knowledge of CMS, Leapfrog, and/or Vizient quality programs

• Strong understanding of clinical documentation, abstraction methodology, and EHR systems (e.g., Epic, Cerner)

• Exceptional organizational skills and attention to detail

• Ability to interpret complex technical specifications and apply them in clinical settings

• Skilled in data analysis and performance interpretation

• Strong interpersonal and leadership abilities with experience guiding high-functioning teams

• Proficient in Microsoft Excel, Word, PowerPoint; experience with BI tools (e.g., Tableau, Power BI) is a plus

• Excellent verbal and written communication skills

Job Details

Legal Employer: NCHEALTH

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: Hybrid

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.