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Position Summary

The Performance Improvement Specialist plays a critical role in advancing Community Health of South Florida’s mission by leading and supporting data-driven quality and performance improvement initiatives across ambulatory healthcare settings. This mid-level position supports continuous improvement in clinical outcomes, patient safety, access to care, and operational efficiency while ensuring compliance with HRSA FQHC requirements, UDS reporting, and The Joint Commission (TJC) Ambulatory Health Care Accreditation standards.

The Specialist collaborates with clinical, administrative, and operational leaders to identify performance gaps, analyze data, implement improvement strategies, and sustain improvements that enhance patient-centered, high-quality care across CHI sites.

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Key Responsibilities

Performance & Quality Improvement

•    Lead and support performance improvement (PI) and quality improvement (QI) initiatives using recognized methodologies such as PDSA, Lean, Six Sigma, or similar frameworks

•    Identify gaps in clinical quality, patient safety, access, and operational performance using data-driven analysis

•    Conduct root cause analyses (RCA) and failure mode evaluations to address adverse trends, incidents, or compliance risks

•    Develop, implement, and monitor corrective action plans and improvement projects aligned with organizational goals

Data Analysis & Reporting

•    Collect, validate, analyze, and interpret clinical and operational performance data, including HRSA UDS measures, internal scorecards, and accreditation-related metrics

•    Develop dashboards, reports, and performance summaries for leadership, committees, and governing bodies

•    Translate complex data into actionable insights to support decision-making at all levels of the organization

Joint Commission Accreditation – Ambulatory Health Care

•    Support compliance with The Joint Commission Ambulatory Health Care Accreditation standards, including performance measurement, patient safety, quality improvement, and continuous readiness

•    Participate in accreditation preparation activities, including tracers, mock surveys, gap analyses, and corrective action planning

•    Ensure performance improvement activities align with TJC standards, National Patient Safety Goals (NPSGs), and evidence-based practices

•    Assist in maintaining documentation, policies, and PI records required for successful surveys and ongoing compliance

FQHC & Regulatory Compliance

•    Support HRSA compliance, including Operational Site Visits (OSVs) and Uniform Data System (UDS) reporting requirements

•    Assist with state, federal, and payer-related quality audits or reviews

•    Ensure documentation of PI/QI activities meets regulatory, accreditation, and organizational requirements

Collaboration & Stakeholder Engagement

•    Partner with medical providers, nursing, behavioral health, care management, and administrative teams across CHI sites

•    Facilitate multidisciplinary PI/QI committees and workgroups

•    Serve as a subject matter resource on performance improvement, data utilization, and accreditation-related standards

Education & Change Management

•    Provide education, coaching, and technical assistance to staff and leaders on quality improvement tools, data interpretation, and accreditation expectations

•    Support change management strategies to promote adoption and sustainability of improvements

•    Foster a culture of continuous quality improvement, accountability, and patient safety

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Required Qualifications

•    Bachelor’s degree in Healthcare Administration, Public Health, Nursing, Quality Management, Business, or a related field

•    Minimum of 3–5 years of experience in healthcare quality improvement or performance improvement

•    Experience in an ambulatory care, community health center, or FQHC environment

•    Working knowledge of healthcare accreditation, quality metrics, and regulatory standards

•    Strong analytical skills with proficiency in Microsoft Excel and healthcare reporting systems

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Preferred Qualifications

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

•    Certification such as CPHQ (Certified Professional in Healthcare Quality), Lean Six Sigma Green Belt, or equivalent

•    Experience supporting The Joint Commission Ambulatory Health Care Accreditation surveys

•    Familiarity with EHR systems, quality dashboards, and population health metrics

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Core Competencies

•    Ambulatory healthcare quality and patient safety

•    Performance improvement methodologies

•    Data-driven decision making

•    Project management and prioritization

•    Strong written, verbal, and presentation skills

•    Cultural competence and commitment to serving diverse and underserved populations

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Key Performance Indicators (KPIs)

•    Demonstrated improvement in targeted clinical and operational performance measures

•    Readiness and successful outcomes for accreditation and regulatory surveys

•    Timely completion and sustainability of PI/QI initiatives

•    Positive engagement and collaboration with clinical and operational stakeholders

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Work Environment

•    Hybrid or on-site work environment based in Miami, Florida

•    Occasional travel to CHI clinical sites required