Quality Improvement Specialist

DSHS is committed to hiring skilled and dedicated individuals who share a passion for public health to pursue our vision of A Healthy Texas. If you are looking to make an impact and tackle new challenges, we encourage you to consider a career with us.

Employee Benefits:

DSHS offers insurance coverage and other benefits available through the State of Texas Group Benefits Plan administered by the Employee Retirement System of Texas (ERS). To learn more about all the benefits available to you as a DSHS employee and other DSHS opportunities for early career pathways, visit the DSHS Careers Page.

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Functional Title: Quality Improvement Specialist 
Job Title: Program Specialist I 
Agency: Dept of State Health Services 
Department: TX Ctr for Infectious Disease 
Posting Number: 18004 
Closing Date: 06/30/2026 
Posting Audience: Internal and External 
Occupational Category: Healthcare Support 
Salary Range: $4,583.00 - $5,372.41 
Pay Frequency: Monthly
Salary Group: TEXAS-B-17 
Shift: Compressed Weekend 
Additional Shift: Days (First) 
Telework: Not Eligible for Telework 
Travel: Up to 5% 
Regular/Temporary: Regular 
Full Time/Part Time: Full time 
FLSA Exempt/Non-Exempt: Exempt 
Facility Location: Texas Center for Infectious Disease 
Job Location City: SAN ANTONIO 
Job Location Address: 2303 SE MILITARY DR 
Other Locations: San Antonio 
MOS Codes: 16GX,60C0,611X,612X,63G0,641X,712X,86M0,8U000,OS,OSS,PERS,YN,YNS 
 
 
 

Brief Job Description:

Under the supervision of the Director of Quality Management, the Program Specialist I in Quality Management (QM) assists in coordinating the compliance, evaluation, and continuous improvement of healthcare services and programs within the hospital. This position supports hospital compliance with Joint Commission, Centers for Medicare & Medicaid Services (CMS), and applicable state and departmental regulatory standards.

Primary responsibilities include researching regulatory standards, developing and maintaining hospital policies and procedures, conducting routine audits and mock tracers, supporting mock survey activities, and assisting with the development and monitoring of Plans of Correction (POCs) for identified compliance gaps. The Program Specialist I works closely with the Quality Management team, hospital leadership, medical staff, and operational departments to support accreditation readiness and ongoing quality improvement efforts.

This position works under limited supervision with latitude for initiative and independent judgment within established guidelines.

Essential Job Functions (EJFs):

Attends work on a regular and predictable schedule in accordance with agency leave policy. [5%]

Monitors hospital compliance with Joint Commission, CMS, and applicable state regulatory standards, by conducting regulatory reviews, tracking compliance activities, identifying gaps, and supporting ongoing survey readiness efforts. [10%]

Researches, interprets, and applies Joint Commission, CMS, and state regulatory requirements and develops, revises, and maintains hospital policies and procedures to ensure alignment with current standards and regulatory expectations. [10%]

Conducts mock tracers, mock surveys, and compliance audits to evaluate accreditation readiness, assess adherence to regulatory requirements, identify opportunities for improvement and monitor implementation of corrective actions. [15%]

Collects, analyzes, and reports quality, patient safety, infection prevention, regulatory compliance, and performance improvement data; develops dashboards, trend analyses, and recommendations to support organizational decision-making, and performance improvement initiatives. [15%]

Coordinates the development, implementation, and monitoring of Plans of Correction (POCs), corrective action plans, and accreditation evidence collection and regulatory readiness activities; collaborates with hospital departments to ensure timely resolution of identified compliance gaps. [15%]

Assists with the coordination, documentation, and follow-up of hospital committees and workgroups, ensuring quality, patient safety, accreditation, and compliance related activities are appropriately tracked and addressed. [15%]

Participates and leads quality improvement activities, including Root Cause Analysis, Failure Mode and Effect Analyses, patient tracers and performance improvement projects designed to improve patient safety, quality of care, regulatory compliance and organization performance. [10%]

Performs other duties as assigned, including participation in disaster response, emergency preparedness, and Continuity of Operations (COOP) activities. [5%]

Knowledge, Skills and Abilities (KSAs):

Knowledge of or experience with Joint Commission and CMS accreditation standards and healthcare regulatory requirements.

Knowledge of policy and procedure development, revision, and document control processes.

Knowledge of performance improvement and quality management principles.

Strong written and verbal communication skills.

Proficiency in Microsoft Word, Excel, and PowerPoint.

Skill in preparing reports and tracking compliance and corrective actions.

Ability to work collaboratively with multidisciplinary teams.

Ability to interpret and apply regulatory requirements in operational and clinical settings.

Ability to analyze data and present findings clearly and accurately.

Ability to conduct or participate in mock tracers, mock surveys, and compliance audits in a hospital or clinical environment.

Registrations, Licensure Requirements or Certifications:

None required

Initial Screening Criteria:

Bachelor’s degree or higher from an accredited college or university.

Minimum of two years of professional experience in a healthcare setting.

Minimum of two years of experience in healthcare quality management, accreditation, regulatory compliance, performance improvement, policy development, nursing, social work, public health, healthcare administration, infection prevention, or risk management.

Additional Information:

MOS Code: N/A

Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified for this position. For more information see the Texas State Auditor’s Military Crosswalk at https://hr.sao.texas.gov/CompensationSystem/JobDescriptions/.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), DSHS will provide reasonable accommodation during the hiring process for individuals with a qualifying disability. If reasonable accommodation is needed to participate in the interview process, please notify the person who contacts you to schedule the interview. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747 or via email at HHSServiceCenter.Applications@ngahrhosting.com.

Salary Information, Pre-employment Checks, and Work Eligibility:

• The salary offered will follow DSHS starting salary guidelines. Any employment offer is contingent upon available budgeted funds.
• Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.
• DSHS uses E-Verify. You must bring your I-9 documentation with you on your first day of work.  Download the I-9 form