This position is responsible for managing and continually improving METRO’s quality and risk management, and compliance program, monitoring compliance/risk activity and investigating allegations of compliance and/or policy infraction.  This position reports to the Senior Director of HC Services and collaborates closely with the Medical Director and senior leadership.


Primary Tasks/Responsibilities:

  • Maintains current knowledge of Federal, State and Accrediting regulations and standards pertaining to ongoing compliance and policy.
  • Leads actions to maintain COA Accreditation, HRSA-FQHC Compliance, DCF Licensing and other applicable state and federal licensing and compliance related entities.
  • Maintains records and manages all METRO’s contracts for compliance.
  • Manages response for subpoenas and oversees Medical Records.
  • Manages METRO’s Medical Records department and monitor Medical Record activities for areas of non-compliance
  • Maintains and monitors the compliance and records for CLIA Waived testing permissions required by the State, local laws and regulations.
  • Implement the onboarding and annual compliance program for staff.
  • Interact with and report to senior management on the status of the compliance activities highlighting any areas of potential risk to the agency.
  • Works closely with team to identify risk prone program and service activities, including but not limited to, patient confidentiality, health record security, health systems security and privacy.
  • Manages Performance & Quality Improvement and Risk Management programs.
  • Leads the PQI team and develops quality improvement reports for PQI committee, staff and Board of Directors.
  • Researches and recommends strategies and best practices and oversees the implementation of programs to increase client/patient quality, operations and customer service.
  • Aggregates annual data and conducts an overall evaluation of the PQI program for efficiency and effectiveness of performance throughout the year.
  • Sets the annual PQI work plan and manages frequency of reporting.
  • Manages data collection and reporting of HRSA Uniform Data System (UDS) required measures.
  • Receives and investigates complaints, near misses, and incidents to resolution.
  • Oversees ongoing competency with METRO’s Emergency Preparedness Plan and schedules regular desktop drills to assess current competence among staff.
  • Plan communication and training programs to help employees understand their roles in risk management.
  • Support Medical Director and Behavioral Health Department in oversight of the peer review process.
  • Manages credentialing and privileging files for LIPs and non-LIPs in compliance with FQHC standards and METRO policies, including required competencies and training.
  • Manage document management software housing METRO’s policies and procedures, credentialing and privileging items, all staff trainings and contracts, to include staff individual accounts and assignments.




  • Minimum Bachelor’s degree in related area.
  • At least 3 years of experience in the areas of quality management, risk management, accreditation, and compliance.
  • Experience working in an FQHC setting preferred.


Knowledge, Skills and Competencies Required:

  • Exceptional planning, communication and organizational skills
  • Must be able to take initiative and coordinate projects with high level of independence
  • Stellar understanding of compliance, risk and quality management concepts and practices.
  • Strong analytical skills and complex problem solving capabilities
  • Ability to work effectively independently and motivate others in team oriented projects
  • Ability to present complex information in simple concise terms
  • Exceptionally detail oriented and strong computer skills required


  • Must possess and maintain valid Florida driver’s license and proof of insurance
  • Must have reliable and accessible auto vehicle.
  • Must pass necessary fingerprinting, Level II background checks and employment eligibility verification through the U. S. Department of Homeland Security’s E-Verify system,

To apply for this job email your details to