Asst Quality Officer

Rochester, NY


To coordinate and process Hospital grievances according to CMS and ACA regulations and to provide oversight of the hospital’s quality assessment/performance improvement program for assigned areas of responsibility.


Under general direction of the Associate Quality Officer for QA, and with latitude for the exercise of independent judgment and initiative:

Coordination of Patient Grievances:

  • Ensures that patient quality grievances are coordinated and completed in accordance with CMS regulations, ACA 1557 Regulations and Hospital policy.

  • Works cooperatively with the Patient and Family Relations Department to determine if patient complaints require follow-up according to the grievance process.

  • Communicates directly with patients and families to manage identified grievance issues and follow-up during the grievance process. Coordinates review of quality grievance issues with involved Hospital departments and summarizes responses in writing for patients and families.

  • Inputs grievance related information into RL Solutions and other databases for tracking and trending of quality of care issues. Develop reports and presentations to communicate and share quality data trends.

  • Have and/or develop in depth knowledge of related regulatory rules and interpretive guidance.

Coordinates and supports quality management initiatives, and assigned councils, programs, services, and service lines in respective quality areas, including:

  • Ensures compliance with the SMH Quality Assessment/Performance Improvement plan (QA/PI) and that the hospital’s plan is in compliance with regulation and accreditation requirements

  • Oversees and reviews QAPI plans and ensures departments are meeting regulatory requirements for QAPI activities

  • Provides education, coordination and support to department QA Liaisons for the QA activities performed in medical staff departments

  • Tracks the status of identified problems and opportunities for improvement to assure resolution or improvement, including tracking of compliance with action plans

  • Provides support to assigned departments for the event reporting system to ensure events are input and event data analyzed by creating reports that depts. can use to track and trend quality and safety concerns.

  • Uses information from the event reporting system, clinical services, the findings of quality assurance studies, quality teams and the clinical and financial databases to detect trends, patterns of performance, or potential quality or safety concerns. These data are reported to the Chief Executive Officer, Medical Director, Medical Staff committees and to the JMQC as well as to the respective departments.

Performs activities as triaged or delegated by the Chief Quality Office or Quality Management Team:

  • Investigates circumstances of cases with adverse patient outcomes, or potential for adverse outcomes

  • Investigates Severe event reports and assignment of appropriate follow-up

  • Facilitates case reviews and root cause analyses, with reporting to NYPORTS as appropriate

  • Facilitates interdisciplinary review of care, as appropriate


Functions independently under the general direction of the Associate Quality Officer, AMH QA Office, and the Chief Quality Officer.


Bachelor’s degree in nursing or a health-related field with 4-5 years of relevant experience; or an equivalent combination of education and experience. Previous experience in Quality Performance Improvement or Patient Safety preferred. Experience working with patients and families to resolve issues preferred. MS Office skills preferred.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $ 76,898 - $107,702 Annually

The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job’s compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Location: Strong Memorial Hospital
Full/Part Time: Full-Time
Opening: Full Time 40 hours Grade 055

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