Opening: Chief Quality & Compliance Officer

Chief Quality & Compliance Officer Position Description

Position Reports to: Chief Executive Officer

Company Values

Here at MHEDS, we are Flexible, Ethical, Positive Communicators, Culturally Competent, Productive, and Team Players.

Summary

The Chief Quality and Compliance Officer (CQCO) is a senior leader responsible for overseeing all quality assurance, compliance, and information security functions at the health center. This includes ensuring compliance with HIPAA and other regulatory standards, managing internal audits, leading UDS reporting and quality improvement initiatives, and aligning workflow development with strategic goals. The CQCO plays a critical role in safeguarding patient data, optimizing clinical and administrative processes, and fostering a culture of continuous improvement and ethical integrity. 

Duties and Responsibilities

Quality Improvement & Compliance

• Develop, implement, and maintain a comprehensive quality and compliance program aligned with HRSA, UDS, and HIPAA standards. 
• Lead the development of workflows and policies that support clinical documentation accuracy and performance improvement initiatives. 
• Ensure timely, accurate UDS data collection, submission, and reporting. 
• Coordinate with department leads to track quality metrics and recommend actions to address gaps in care. 
• Oversee internal audit procedures and ensure compliance with federal, state, and local regulations. 

Information Security & Data Governance

• Oversee all activities related to information technology security, including risk assessments, mitigation planning, and breach prevention. 
• Serve as the health center’s HIPAA Privacy and Security Officer. 
• Develop and monitor policies related to secure handling of electronic health information. 
• Ensure clinical and administrative staff are trained on privacy and data security protocols.

Organizational Leadership & Workflow Optimization

• Guide and evaluate workflow development across departments to improve efficiency and quality outcomes. 
• Collaborate with clinical leadership to align compliance, EHR utilization, and performance targets. 
• Serve as the lead for patient safety and continuous quality improvement activities, integrating SDOH strategies and evidence-based practices. 

Communication & Reporting

• Prepare and present regular performance, compliance, and risk management reports to executive leadership and the Board of Directors. 
• Foster a culture of transparency, responsiveness, and ethical conduct across all organizational levels. 

Safety

• Adheres to safety, infection control, patient confidentiality, and related policies and procedures.

Company Values

• Ensures the six domains of healthcare quality are met during each patient visit: patient safety, effectiveness, patient-centered, timeliness, efficiency, and equity. 
• Consistent with MHEDS’ values, treats all supervisors, co-workers, direct reports, patients, and any other internal or external person with respect and dignity. 
• All other duties as assigned by supervisor and/or based on the needs of the health center. 

Supervisory Capacity

Directly supervises staff and/or consultants involved in quality, compliance, or data infrastructure. Participates in hiring, training, and performance evaluations for supervised personnel. 

Education and/or Experience

• Bachelor’s degree in Public Health, Healthcare Administration, Nursing, Health Informatics, or related field required; Master’s degree preferred.
• Minimum 5 years of experience in a healthcare quality, compliance, or informatics leadership role.
• Familiarity with FQHC or FQHC Look-Alike compliance standards and UDS reporting required. Experience in workflow development and EHR (eClinicalWorks preferred) optimization. 

Knowledge, Skills & Abilities

• Strong understanding of HIPAA, HITECH, and data privacy laws. 
• Demonstrated ability to lead interdisciplinary teams and drive systemic change. 
• Excellent analytical, organizational, and communication skills. 
• Proficient in Microsoft Office Suite and EHR data tools.

Language Skills

Must be able to speak and write in English. Additional language capabilities are a plus.

Physical Demands

Normal medical/administrative office setting demands include lifting and carrying or delivering supplies that usually weigh less than 10 pounds, but may occasionally weigh 20-30 pounds, within the building. Must be able to move between site locations during the work day as job duties require.

Work Environment

The office and clinical areas are well illuminated, climate controlled, indoor areas. Work involves some exposure to hazards typical to a medical office environment, including potential exposure to infectious diseases and blood borne pathogens, chemical exposures, fire, mechanical and electrical hazards. Protective clothing and equipment are provided and required to be worn in potential exposure situations.

About Multi-Cultural Health Evaluation Delivery System (MHEDS)

MHEDS was established 50 years ago as a joint project of the Erie Diocesan Mission Office and the Erie Council of Churches to meet the health needs of African-American and Hispanic Farm Workers and other low-income individuals and their families. Refugee and immigrant health were added in the late 1990s. On January 1, 2019, MHEDS entered the Federally Qualified Health Center system as a Look-Alike.

Our service area is the City of Erie. Our mission is to enable all who wish to achieve complete mental, physical and social well-being by providing equitable, culturally sensitive, patient-centered health care, regardless of their ability to pay. MHEDS has a very diverse panel of patients: 35% are Asian, 29% Black/African American, 29% White, and the remainder mixed race. 6% are Latino/a. As an FQHC Look-Alike, MHEDS must comply with standards that ensure all patients have access to comprehensive health care services. We also offer health insurance enrollment, interpretation, and translation.

MHEDS expanded by opening a second site at the JFK Center in 2020. The second site allowed us to begin to offer women’s health and accommodation to serve more new arrivals. In late 2021, MHEDS began receiving Afghan refugees along with its anticipated arrivals. In early 2022 we began receiving Ukrainian refugees. Our anticipated 549 new patients became 1,010. This Federal Fiscal Year, we have been told to expect 750 refugees plus additional Afghans and an unknown number of Ukrainians. Eighty percent of MHEDS’ staff are hired from within the New American group, allowing us to be more aligned both linguistically and culturally with those we serve.