Administration - Director of Operations

Summary:

The Director of Operations provides strategic and operational leadership across key service areas, including clinical operations, patient services (front desk), quality improvement, call center management, compliance, risk management, patient relations, and information technology. This position plays a critical role in ensuring organizational efficiency, regulatory compliance, and a high-quality, patient-centered experience within the Federally Qualified Health Center (FQHC) model. Reporting directly to the Chief Executive Officer (CEO) and working closely with the Chief Financial Officer (CFO), the Director ensures that systems and workflows support operational excellence, cultural responsiveness, and SDAIHC’s mission to provide accessible, comprehensive, and culturally respectful healthcare services.

Essential Duties and Responsibilities:

Program Management and Operations:

1. Oversee daily clinical and administrative operations to ensure efficient workflows, timely patient flow, and consistent delivery of high-quality services.
2. Lead the development, implementation, and ongoing improvement of policies, procedures, and operational systems across all departments.
3. Ensure organizational compliance with applicable federal, state, and local regulations, including HRSA, OSHA, HIPAA, and FQHC operational standards.
4. Provide oversight of facility operations and information technology systems, including EHR optimization and coordination with internal IT and external vendors.
5. Direct all aspects of the Refugee Health Assessment Program (RHAP), ensuring timely, complete, and accurate health assessments in accordance with contractual requirements set by the County of San Diego.
6. Monitor performance metrics and prepare regular reports for internal leadership and external partners, ensuring accountability and program effectiveness.

Operational Excellence:

1. Lead the development and implementation of quality improvement initiatives aligned with UDS, HEDIS, and other clinical and operational benchmarks.
2. Monitor performance metrics and lead corrective action planning for underperforming areas.
3. Identify and implement innovative solutions to improve operational efficiency and patient care.

4. Lead operational audits, risk mitigation strategies, and accreditation readiness efforts.

Staff Leadership and Development:

1. Serve as a key member of the executive leadership team, contributing to organizational strategy, policy development, and operational planning.
2. Lead interdisciplinary improvement initiatives and organizational readiness for growth and change.
3. Report regularly to the CEO on key performance indicators, risk trends, and operational initiatives.
4. Provide strategic leadership and direct supervision to a diverse team of operational managers and staff, ensuring alignment with organizational goals and priorities.
5. Promote a culture of high performance, accountability, and continuous improvement through clear expectations, regular feedback, and results-driven management.
6. Foster a positive, inclusive, and collaborative workplace culture that supports employee engagement, well-being, and professional growth.
7. Ensure operational practices comply with all applicable labor laws, HRSA requirements, and internal organizational policies and procedures.

Compliance and Quality Assurance:

1. Ensure full compliance with federal, state, and local regulations, including accreditation standards and FQHC-specific requirements.
2. Lead risk management initiatives by proactively identifying, assessing, and mitigating operational and clinical risks.

3. Oversee regular audits, assessments, and internal reviews to ensure ongoing compliance, quality assurance, and readiness for external evaluations.
4. Plan, implement, and maintain a comprehensive Quality Improvement (QI) program, including staff training to enhance understanding of QI systems and improve performance on measures such as HEDIS and GPRA.
5. Monitor compliance with internal and external quality standards by reviewing workflows, medical records, and documentation to ensure delivery of high-quality, patient-centered care.
6. Apply advanced knowledge of clinical quality principles, practices, and tools—including data analytics and QI-related technology platforms—to drive performance improvement.
7. Provide education and coaching to staff and managers, fostering a culture of continuous improvement and care transformation.
8. Advise clinic leadership on Meaningful Use requirements and strategies for Electronic Health Record (EHR) optimization.
9. Lead initiatives to maximize the use of health information technology to enhance clinical outcomes, operational efficiency, and data reporting capabilities.
10. Facilitate QI and performance improvement project cycles, including team development, project planning, workflow redesign, implementation, and outcome evaluation.

Risk Management:

1. Develop, implement, and maintain the organization's risk management program, including policies, procedures, and response protocols aligned with FQHC standards.
2. Establish and oversee a standardized incident reporting system to ensure timely identification and documentation of potential risks, safety concerns, or compliance violations
3. Lead investigations of reported incidents, conduct root cause analyses, and implement corrective action plans to prevent recurrence and reduce organizational risk.
4. Maintain comprehensive and confidential records of incidents, investigations, resolutions, and follow-up actions in accordance with regulatory requirements.
5. Design and manage risk management and compliance training programs for staff at all levels, fostering a culture of safety and accountability.
6. Promote organization-wide awareness of risk management protocols and encourage consistent application of safety practices in daily operations.
7. Provide ongoing education and communication regarding regulatory changes, risk trends, and best practices in healthcare risk mitigation.

Emergency Preparedness:

1. Develop, implement, and maintain comprehensive emergency preparedness and response plans in alignment with HRSA, OSHA, and local regulatory requirements.
2. Conduct regular emergency drills, tabletop exercises, and staff training to ensure organizational readiness and effective response in crisis situations.
3. Collaborate with local emergency response agencies, public health departments, and community partners to coordinate planning efforts and strengthen response capabilities.

Data Security and Privacy:

1. Ensure compliance with data security and privacy regulations, including HIPAA.
2. Conduct regular audits of data security practices and implement corrective actions as needed.
3. Respond to data breaches and manage the investigation and reporting process.

Stakeholder Engagement:

1. Champion a patient-centered approach to healthcare delivery by promoting accessibility, cultural sensitivity, and service excellence across all departments.
2. Build and maintain strong relationships with community organizations, stakeholders, and partners to support outreach efforts, improve health equity, and enhance service delivery.

Strategic Planning:

1. Collaborate with the CEO to guide strategic planning efforts, ensuring alignment with SDAIHC’s mission and the evolving needs of the refugee and broader patient populations.
2. Identify and pursue opportunities for program growth, service enhancement, and additional funding to expand impact and sustainability.
3. Develop and implement operational strategies that support the organization’s mission, strategic goals, and performance expectations.
4. Establish and track key performance indicators (KPIs), goals, and operational plans to drive efficiency, service excellence, and organizational growth.
5. Lead change management initiatives in response to shifts in healthcare policy, funding, and community needs, fostering a culture of adaptability, innovation, and continuous improvement.
6. Other duties as assigned

Required Qualifications:

1. Master’s degree in public health, Healthcare Administration, Social Work, or related field.
2. Minimum of five years of experience in program management, preferably in healthcare or community services.
3. Strong understanding of compliance requirements for health programs, especially those funded by government contracts.
4. Proven leadership skills with a track record of developing effective teams.
5. Excellent communication and interpersonal skills, with the ability to engage effectively with diverse stakeholders.

Desired Qualifications:

1. Experience in managing government-funded programs.
2. Knowledge of the healthcare needs of the Native American community.
3. ECW EHR.

Special Conditions of Employment:

1. CPR/ BLS certification:Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
2. Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
3. For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
4. Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego American Indian Health Center (SDAIHC).

Knowledge, Skills, and Abilities:

1. Strong leadership and management capabilities.
2. Excellent analytical and data interpretation skills.
3. Effective communication and presentation skills.
4. Ability to build and maintain collaborative relationships with a diverse range of stakeholders.
5. Attention to detail development and maintenance of regulatory paperwork.
6. Ability to work independently, as well as to be part of a collaborative team.
7. Strong presentation skills and ability to create needed educational materials.
8. Excellent written and oral communication skills.
9. Computer competence, highly effective collaboration, written and verbal communications skills.
10. Attention to detail development and maintenance of regulatory paperwork.
11. Excellent oral and written communication skills.
12. Computer proficiency, including programs such as MS Office, Word, Excel, email, and internet research, required.
13. Must possess the ability to educate and train Compliance and Clinical standards to staff members.
14. Excellent organizational skills and attention to detail.
15. Ability to maintain confidentiality and meticulous records.
16. Able to deal effectively with a diversity of individuals.
17. Ability to establish and maintain cooperative working relationships with all during the course of work.
18. Able to perform basic mathematical calculations necessary to perform the job function.
19. Must be reliable and extremely trustworthy. 
20. Demonstrated proficiency in Microsoft Suite or related programs.

Physical and Mental Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without accommodation.

1. Able to lift/move up to 10 pounds, move from place to place.
2. Able to sit at a desk and work on a computer for prolonged periods.
3. Able to stand, bend and reach for prolonged periods.
4. Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
5. Ability to supervise, multitask, understand, and follow instructions.
6. Ability to proficiently read, write, speak, and understand English.

Customer Service:

1. Actively supports, promotes, and works to fulfill the Mission, Vision, and core values of SDAIHC.
2. Provides excellent internal and external customer service.
3. Demonstrates SDAIHC’s Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.
4. Participates in on-going customer service training.
5. In every action, seeks to promote SDAIHC as a top service organization.

Safety:

1. Ensures regulatory compliance and adherence with policies and procedures related to safe work practices.
2. Participate in infection prevention through appropriate use of infection control measures during patient treatment and patient interactions.
3. Ensure compliance with regulatory requirements for maintaining physical spaces, equipment, and supplies.  
4. Uses all appropriate equipment and/or tools to ensure workplace safety. 
5. Immediately reports unsafe working conditions. 

Privacy/Compliance:

1. Maintains privacy and security of all patients, employee, and volunteer information and access to such information. Such information is accessed on a need-to-know basis for business purposes only. 
2. Complies with all regulations regarding corporate integrity and security obligations. Reports unethical, fraudulent, or unlawful behavior or activity.
3. Upholds strict ethical standards.

Flexibility:Available for all shifts and, when required, able to work evenings and weekends

Disclaimer

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.  This description reflects managements’ assignment of essential functions.  It does not prescribe or restrict the tasks that may be assigned.  This job description is subject to change at any time.

Preference is given to qualified American Indian/Alaskan Natives in accordance with the American Indian Preference Act (Title 25, U.S. Code Section 472, 473 and 473a). In other than the above, the San Diego American Indian Health Center, is an equal opportunity employer.

San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation, or belief.