DESCRIPTION: The Chief Operating Officer (COO) provides executive leadership and oversight of the Center’s day-to-day operations and supports the Chief Executive Officer (CEO) in implementing the Center’s mission, strategic plan, and organizational priorities. The COO works collaboratively with the CEO, Chief Financial Officer, Chief Medical Officer, Chief Dental Officer, executive leadership, directors, and managers to ensure that clinical and administrative operations are efficient, compliant, financially responsible, patient-centered, and responsive to community needs.
The COO is responsible for translating the Center’s strategic goals into operational plans, performance expectations, and measurable outcomes. This position oversees designated clinical support and administrative departments, promotes collaboration across service lines and locations, and leads efforts to improve patient access, operational efficiency, service quality, employee accountability, and organizational performance.
The COO currently also serves as the Chief Quality Officer and provides executive oversight of the Center’s quality improvement, compliance, risk management, patient safety, privacy, and related regulatory functions. The COO serves as the Center’s Compliance Officer, Privacy Officer, and Risk Manager unless otherwise designated by the Chief Executive Officer.
SUPERVISION: Reports directly to the Chief Executive Officer.
SUPERVISES: Chief of Clinical Services, Chief Information Officer, Director of Pharmacy, Director of Quality Improvement & Risk Management, Director of Health Education & Training, Health Information Manager, CSR/Care Coordination Manager, Registration Manager, Eligibility Manager, and the Administrative Assistant.
TYPICAL PHYSICAL DEMANDS: Requires prolonged periods of sitting, standing, walking, and working at a computer. Must be able to bend, reach, and occasionally lift or carry items weighing up to 25 pounds. Frequent use of standard office equipment, including computers, telephones, printers, and copiers. Travel between Center locations and to community meetings, conferences, trainings, regulatory reviews, and other business-related activities is required. The position may occasionally require extended hours, evening meetings, or weekend responsibilities.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
EXECUTIVE LEADERSHIP AND STRATEGIC PLANNING
- Supports the CEO in the overall leadership, administration, and strategic direction of the Center.
- Represents the CEO at meetings, functions, community events, and other activities as directed.
- Acts on behalf of the CEO during the CEO’s absence within the scope of authority delegated by the CEO and the Board of Directors.
- Participates as a member of the executive management team and contributes to organizational planning, policy development, problem-solving, and executive decision-making.
- Assists with the development, implementation, evaluation, and regular updating of the Center’s strategic plan.
- Translates strategic goals into operational priorities, departmental work plans, performance measures, timelines, and accountable outcomes.
- Coordinates the Center’s internal planning activities and ensures that departmental goals support the Center’s mission, strategic plan, Health Center Program requirements, and community needs.
- Advises the CEO regarding significant operational, regulatory, compliance, quality, financial, workforce, or patient-care concerns.
- Provides leadership during organizational emergencies, operational disruptions, public health events, and business continuity situations.
- Promotes a culture of accountability, collaboration, patient safety, service excellence, ethical conduct, and continuous improvement
OPERATIONAL OVERSIGHT
- Provides executive oversight of assigned departments, programs, managers, and operational functions.
- Establishes performance expectations for directly supervised leaders and holds departments accountable for operational, financial, quality, compliance, and service-related outcomes.
- Evaluates the effectiveness of the Center’s administrative and clinical support operations and recommends changes to improve efficiency, productivity, access, quality, and patient satisfaction.
- Develops, implements, and monitors operational policies, procedures, workflows, and performance standards.
- Promotes consistent operational practices across Center locations while allowing for appropriate site-specific needs.
- Facilitates coordination among clinical, administrative, financial, information technology, pharmacy, health information, registration, eligibility, care coordination, and support departments.
- Identifies operational barriers, workflow concerns, staffing challenges, and service gaps and works with appropriate leaders to implement corrective action.
- Oversees operational readiness for new programs, service expansions, clinic locations, technologies, and organizational initiatives.
- Monitors patient access, scheduling, registration, eligibility, referral coordination, patient flow, customer service, and continuity-of-care processes.
- Supports efforts to improve appointment availability, reduce delays, address patient complaints, and strengthen the patient experience.
- Reviews departmental performance data and operational reports to identify trends, risks, opportunities, and areas requiring intervention.
- Ensures that operational decisions are supported by reliable data, organizational priorities, regulatory requirements, and available resources.
- Conducts regular meetings with supervised leaders to review performance, priorities, staffing, barriers, corrective actions, and progress toward established goals.
- Provides leadership, coaching, development, and evaluation for employees who report directly to the COO
QUALITY IMPROVEMENT AND PATIENT SAFETY
- Provides executive oversight of the Center’s quality improvement, performance improvement, patient safety, and risk-management programs.
- Ensures that the Center’s quality improvement program is structured, data-driven, documented, and aligned with organizational goals, patient needs, regulatory requirements, and recognized standards of care.
- Collaborates with clinical and administrative leadership to establish annual quality goals, performance measures, improvement activities, and reporting expectations.
- Oversees the evaluation of clinical, operational, patient-experience, and service-delivery data to identify opportunities for improvement.
- Ensures that quality improvement findings are communicated to appropriate leaders and incorporated into operational and clinical processes.
- Promotes the use of corrective action plans, root-cause analysis, process mapping, audits, and other improvement methods when performance concerns are identified.
- Ensures that quality improvement and patient-safety activities are appropriately documented and reported to executive leadership and the Board of Directors.
- Supports the development of a culture in which employees are encouraged to report safety, quality, compliance, and operational concerns without fear of retaliation
COMPLIANCE, PRIVACY, AND RISK MANAGEMENT
- Serves as the Center’s Compliance Officer and Privacy Officer.
- Provides oversight of the Center’s compliance, privacy, security, and risk-management programs.
- Ensures that the Center maintains an effective compliance program that includes policies, education, reporting mechanisms, monitoring, auditing, investigation, corrective action, and appropriate oversight.
- Evaluates allegations and determines whether an investigation, audit, corrective action, consultation, or referral is necessary.
- Ensures that investigations are conducted promptly, objectively, confidentially, and in coordination with Human Resources, legal counsel, clinical leadership, or other appropriate parties.
- Ensures that confirmed or potential violations are appropriately documented, corrected, escalated, and reported when required.
- Monitors corrective action plans resulting from investigations, audits, regulatory findings, complaints, incidents, or identified compliance concerns.
- Oversees processes for receiving, documenting, reviewing, investigating, and responding to patient safety events, incidents, claims, grievances, privacy concerns, and risk-management matters.
- Serves as the primary organizational contact for claims-related activities unless otherwise designated.
- Coordinates the timely processing, documentation, review, and follow-up of claims and potential claims.
- Works with applicable insurers, federal representatives, legal counsel, clinical leaders, and other parties regarding claims and risk-management matters.
- Provides support for claim-file reviews, incident reviews, risk assessments, and corrective action activities.
- Identifies trends in incidents, claims, complaints, privacy events, and operational risks and recommends preventive action.
- Oversees compliance with applicable patient privacy and confidentiality requirements, including the Health Insurance Portability and Accountability Act and other applicable federal and state requirements.
- Collaborates with the Chief Information Officer and Health Information Manager regarding privacy, information security, access controls, breach-response procedures, and protection of health information.
- Ensures that the Center maintains appropriate reporting processes that protect employees and other individuals from retaliation for good-faith reporting
REGULATORY AND ACCREDITATION
- Maintains a working knowledge of federal and state healthcare laws, regulations, funding requirements, accreditation standards, and developments affecting federally qualified health centers.
- Ensures operational compliance with applicable Health Resources and Services Administration Health Center Program requirements, including the Health Center Program Compliance Manual and related oversight requirements.
- Coordinates organizational readiness for HRSA Operational Site Visits, accreditation surveys, state reviews, funding-source reviews, and other regulatory or external evaluations.
- Develops and maintains survey-readiness plans, document-management processes, assignments, timelines, and corrective action tracking.
- Coordinates responses to findings, recommendations, plans of correction, and follow-up requests resulting from site visits, audits, accreditation surveys, or regulatory reviews.
- Monitors the Center’s healthcare and business plans in accordance with Health Center Program grant goals, objectives, approved scope of project, and organizational priorities.
- Assists with maintaining compliance related to the Center’s Federal Tort Claims Act deeming requirements and risk-management obligations.
- Collaborates with appropriate leaders to monitor compliance with applicable requirements related to credentialing, privileging, quality improvement, patient safety, pharmacy services, health information management, information technology, and clinical operations.
- Keeps executive leadership informed of federal and state legislative developments, regulatory changes, and FQHC-related developments that may affect Center operations
FINANCIAL AND CONTRACTUAL OVERSIGHT
- Collaborates with the Chief Financial Officer to monitor operational expenditures, encumbrances, revenue, productivity, and financial performance.
- Participates in annual budget development and assists supervised departments with developing and managing departmental budgets.
- Reviews operational and financial data to identify cost-saving opportunities, inefficient processes, revenue concerns, and resource needs.
- Supports efforts to strengthen revenue-cycle performance through effective registration, eligibility, documentation, workflow, and operational practices.
- Develops and monitors strategies to increase and maintain appropriate third-party payer participation and patient access to covered services.
- Participates in the review and negotiation of payer agreements and other third-party contracts as assigned.
- Reviews contracts, agreements, memoranda of understanding, and business arrangements within the COO’s assigned areas and provides operational recommendations.
- Coordinates contract review with the CEO, Chief Financial Officer, legal counsel, compliance personnel, and department leaders as appropriate
DATA, REPORTING, AND PERFORMANCE MANAGEMENT
- Collaborates with the Chief Financial Officer, Chief Information Officer, clinical leadership, and other responsible staff in the collection, validation, analysis, and reporting of organizational data.
- Assists with the coordination, review, and submission of the Uniform Data System report and other required federal, state, accreditation, grant, or organizational reports.
- Ensures that reported data are accurate, complete, timely, and supported by appropriate documentation and validation processes.
- Uses comparative, trend, benchmark, productivity, quality, access, and financial data to support organizational decision-making.
- Ensures that supervised departments establish measurable performance goals and regularly evaluate progress.
- Presents operational, quality, compliance, risk-management, and strategic performance information to executive leadership and the Board of Directors as requested.
MINIMUM QUALIFICATIONS:
- Master’s degree from an accredited college or university in healthcare administration, public health, business administration, public administration, nursing, health services administration, organizational leadership, or a closely related field or working towards completion of Master’s degree.
- A combination of a bachelor’s degree in a related field and substantial executive-level healthcare leadership experience may be considered in place of a master’s degree.
- At least seven years of progressively responsible leadership experience in healthcare operations, including at least five years in a senior management leadership position.
- Experience overseeing multiple departments, programs, service lines, or healthcare locations.
- Experience working with healthcare financial information, operational budgets, productivity measures, contracts, data reporting, and performance indicators.
- Experience preparing for or participating in regulatory, accreditation, grant, or compliance reviews.
- Experience in a federally qualified health center, community health center, safety-net healthcare organization, or similar ambulatory healthcare environment is strongly preferred.
- Experience with HRSA Health Center Program requirements, Section 330 grants, Uniform Data System reporting, Federal Tort Claims Act requirements, Joint Commission accreditation, or similar regulatory frameworks is strongly preferred.
- Experience overseeing quality improvement, compliance, privacy, risk management, information technology, health information management, patient access, pharmacy, or other healthcare support operations is preferred.
SKILLS AND ABILITIES:
- Comprehensive knowledge of healthcare operations, organizational leadership, strategic planning, and process improvement.
- Working knowledge of federally qualified health center operations, Health Center Program requirements, healthcare accreditation standards, patient privacy requirements, quality improvement, risk management, and compliance principles.
- Demonstrated ability to lead multidisciplinary teams and develop directors, managers, and emerging leaders.
- Strong analytical skills and the ability to interpret financial, operational, clinical, quality, workforce, and patient-experience data.
- Ability to identify organizational risks, evaluate complex situations, develop practical solutions, and make timely decisions.
- Knowledge of continuous improvement methods and the ability to lead corrective action, performance improvement, workflow redesign, and organizational change.
- Ability to interpret and apply laws, regulations, grant requirements, accreditation standards, contracts, policies, and organizational procedures.
- Ability to manage sensitive compliance, privacy, risk, claims, and employee-related matters objectively and confidentially.
- Excellent verbal, written, interpersonal, presentation, negotiation, and public-speaking skills.
- Ability to communicate complex operational or regulatory information clearly to the Board of Directors, executive leadership, employees, community partners, and external agencies.
- Ability to build effective working relationships with clinical leaders, employees, patients, regulators, funders, community organizations, government representatives, and other stakeholders.
- Ability to remain composed and provide leadership during emergencies, investigations, regulatory reviews, operational disruptions, and other high-pressure situations.
- Demonstrated commitment to patient-centered care, health equity, cultural responsiveness, ethical leadership, employee engagement, and service to medically underserved communities.
- Ability to protect confidential and privileged information and exercise a high degree of discretion and sound judgment.
- Must possess reliable transportation, maintain automobile insurance as required by law, and hold a valid Texas driver’s license.
