Position Classification Description

Position Class Code / Title: S7004 / Mgr,Clinical Qlty Improvement
Recruitment Tier: Tier 1
FLSA: Exempt
Grade: 14
HR Review/Approval:COMP

This is a description of a Staff Position Classification. It is not an announcement of a position opening. To view descriptions of current openings, please go to UNMJobs and Search Postings to view positions that are currently accepting applications.

The following statements are intended to describe, in broad terms, the general functions and responsibility levels characteristic of positions assigned to this classification. They should not be viewed as an exhaustive list of the specific duties and prerequisites applicable to individual positions that have been so classified.


Develops and manages a Quality Improvement Program through the design, implementation, coordination and evaluation of quality improvement initiatives for a designated department or departments through research, data management, data analysis and data reporting. Supports the identification and development of goals, objectives, policies and procedures for key strategic plans and process improvement initiatives. Works in partnership with UNMH, UNMMG and Quality Outcomes group on joint quality improvement efforts and initiatives.

Duties and Responsibilities

  1. Manages and performs analysis in the measurement and tracking of various clinical programs and provides insights to long-term quality measurement strategies by ensuring data quality and integrity.
  2. Develops and maintains a system for the identification, collection, and analysis of measurement data.
  3. Manages the collection, development, analysis, and communication of measurement data that will be used to establish benchmarks and to support decision making, problem solving and planning for continuous quality improvement.
  4. Assesses reporting requirements and develops and disseminates statistical and narrative reports to appropriate end users, including senior leadership.
  5. Plans, develops, coordinates, and presents specific training and educational programs as appropriate to the quality assurance needs of the facility or service.
  6. Studies and evaluates national trends, clinical standards, and benchmark measures to enhance compliance efforts.
  7. Works with school and physician leadership to ensure ongoing compliance with quality improvement work plans and standards.
  8. Develops and maintains any database(s) necessary for the functions detailed above, and creates system(s) to ensure the integrity of the data therein.
  9. Performs miscellaneous job-related duties as assigned.

Minimum Job Requirements

  • Bachelor's degree; at least 5 years of experience directly related to the duties and responsibilities specified.
  • Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.

Knowledge, Skills and Abilities Required

  • Strong written, verbal and presentation communication skills.
  • Demonstrated proficiency with Microsoft Office Suite, including WORD, Excel, PowerPoint, and Access. Familiarity with other relational databases as necessary.
  • Demonstrated experience in project planning, leadership and training.
  • Ability to identify and resolve data problems, ensuring data integrity, accuracy and consistency.
  • Knowledge of project management principles, practices, techniques, and tools.
  • Strong interpersonal skills and ability to work effectively at all levels in a collaborative team environment.
  • Familiarity with formal quality and process improvement programs such as LEAN and Six-Sigma.
  • Working knowledge of core measures of performance, patient safety and mortality improvement in a health care setting.

Conditions of Employment

  • Successful candidate must submit to post-offer, pre-employment physical examination and medical history check.

Working Conditions and Physical Effort

  • Work is normally performed in a typical interior/office work environment.
  • No or very limited exposure to physical risk.
  • No or very limited physical effort required.

The University of New Mexico provides all training required by OSHA to ensure employee safety.

Revised Date: 10/26/2018