Facility Healthcare Program Manager (O-5 Billet) Non-Supervisory

This position is open only to USPHS Commissioned Corps officers and Call to Active Duty (CAD) candidates.

About the Role

The Facility Healthcare Program Manager (FHPM) oversees healthcare operations at medium to large ICE Health Service Corps (IHSC) facilities, ensuring compliance with accreditation standards, risk management, and quality improvement. The FHPM reports to the Assistant Health Services Administrator (AHSA) and manages clinical programs, staff training, emergency preparedness, and supports safe, high-quality care delivery.

Responsibilities

• Serve as the subject matter expert and key advisor in the day-to-day management, development, implementation, and monitoring of IHSC programs, including accreditation readiness, standards compliance, risk management, and quality improvement.
• Act as a key member of IHSC national risk management and quality improvement program initiatives, including attending regional and national meetings.
• Monitor, review, coordinate, and ensure complete and timely reporting of accreditation readiness, standards compliance, risk management, and quality improvement activities.
• Conduct data and trend analysis, implement improvement strategies, and establish timeframes for continued monitoring across all programs of responsibility.
• Maintain all files and information related to programs of responsibility in accordance with established policies, procedures, and regulations.
• Develop and maintain local operating procedures for accreditation readiness, standards compliance, risk management, quality improvement, infection control, occupational health, environmental health, safety and security, and all-hazards emergency preparedness and response; forward revisions and updates to the Health Services Administrator (HSA) for approval.
• Ensure timely dissemination of compliance standards, policy updates, and procedures to staff.
• Regularly coordinate efforts with the Facility Health Services Officer (FHSO), Facility Training Officer (FTO), and Infection Prevention Officer (IPO).
• Provide policy, records, or other documentation as required by investigators.
• Serve as a federal fit tester, conducting fit testing for federal staff and ensuring all staff meet annual fit testing requirements.
• Perform duties of the FHSO programs (infection control, occupational health, environmental health, safety and security, and all-hazards emergency preparedness and response) when needed.
• Serve as acting HSA or AHSA when required.
• Travel up to 25% as directed by the Chief of Health Operations Unit.

Accreditation

• Monitor and review established performance indicators for compliance with national IHSC policies and applicable standards (ACA, NCCHC, PBNDS, and/or FRS).
• Collaborate with the HSA and AHSA in performing assessments of the health unit for accreditation under appropriate standards and ensure preparation for accreditation audits.
• Prepare the facility for accreditation/re-accreditation audits by reviewing processes, updating policies, training staff, and organizing audit documentation.
• Develop recommendations for improvements and success action plans if deficiencies are identified during audits or health systems assessments.
• Participate in the Quality Review Process, including performing self-assessments, pre-audit reviews, and observations.
• Serve as a liaison between investigators and facility staff, arrange interviews, and provide required documentation.
• Prepare responses to action items in coordination with FHSO, FTO, and IPO.

Risk Management

• Provide leadership and oversight of the local risk management program, including developing, coordinating, implementing, and monitoring associated tasks.
• Assist the HSA and AHSA with the investigation of incident reports and adverse events (e.g., root cause analysis, mortality reviews).
• Conduct data and trend analysis, develop action plans, implement improvement strategies, and monitor effectiveness of changes.
• Prepare facility responses to correct identified process issues and report findings and recommendations in writing through established chains of communication.

Quality Improvement

• Provide leadership and oversight of the local quality improvement (QI) program, including developing, coordinating, implementing, and monitoring national and local performance measures.
• Chair local QI committee meetings.
• Conduct data and trend analysis, implement improvement strategies, and establish timeframes for continued monitoring.
• Complete quarterly and annual reports and communicate findings to staff in a timely manner.
• Identify, conduct, analyze, and evaluate studies (e.g., patient education, process, outcome, healthcare failure modes and effects analysis).
• Educate staff on rationale, procedures, and subsequent process changes.
• Report findings, recommendations, and education in writing through established chains of communication.

Training

• Provide leadership, oversight, and staff training on compliance with standards and accreditation, risk management (e.g., incident reporting, patient safety), and quality improvement.
• Assist the HOST FHPM with new FHPM orientation as needed.
• Coordinate with the FTO on all trainings and obtain HSA and AHSA approval prior to implementation.
• Serve as a CPR Instructor and conduct BLS certification for all federal staff, providing CPR cards upon completion.

Requirements

• Must be a U.S. citizen.
• Must successfully pass a background investigation and drug screen.
• Males born after 12/31/59 must certify registration with Selective Service.
• Must be a current USPHS Commissioned Corps Officer or USPHS Call to Active Duty (CAD) candidate; civilians are not eligible.
• Must participate in the IHSC TDY On-Call Schedule (ITOS), which requires availability for either an entire month or two 16-day periods per year.
• Must not have a current Assignment Pay Agreement, or if one exists, it must be fulfilled within 90 days of application submission.
• Upon appointment, officers must serve an 18 to 24-month commitment to IHSC.

Physical Demands

• Position is considered hazardous duty in a detention setting.
• Required to walk unaided at a normal pace for up to 5 minutes and maintain balance.
• Required to jog or fast walk up to ¼ mile.
• Must be able to lift objects greater than 30 pounds and perform CPR/emergency care while standing or kneeling.
• Must assist sick, injured, or aging detainees or staff exiting the building, which may require lifting, dragging, wheeling, or carrying someone significantly heavier than self.
• Must be able to see, hear, and smell with aids if necessary.
• Must perform duties in a stressful and often austere environment without physical limitations.

Qualifications

• Minimum of a master’s degree in a qualifying program for USPHS Commissioned Corps officers.
• Minimum of five years of relevant and related experience.
• If holding a clinical license, the incumbent is responsible for maintaining its current status and may be required to perform clinical activities within the scope of that license during critical agency needs.
• Strong project management, quality management, and performance improvement skills, including planning, prioritizing workload, conducting surveillance, and analyzing data.
• Proficiency with electronic health records and ability to quickly develop competency with IHSC’s electronic health record system.
• Ability to quickly develop competency in ICE and IHSC rules, regulations, and policies; applicable detention healthcare standards (PBNDS, NCCHC, ACA, FRS); OSHA regulations; and NFPA Life Safety Codes.
• Proficiency with Microsoft Word and Excel, including managing, organizing, and analyzing complex information using spreadsheets and other data management tools.
• High-level professional written and verbal communication skills, effective teaching skills, and ability to prepare reports in electronic formats.
• Maintains basic readiness status and current CPR/BLS certification.

Supervisory Controls

The incumbent reports to the Assistant Health Services Administrator (AHSA) and keeps the supervisor informed on project status, consulting on successes and obstacles. The reviewing official (second-line supervisor) is the Health Services Administrator (HSA).

• Performs specialized or complex professional tasks without close supervision or detailed guidelines, independently establishing criteria and formulating approaches.
• Uses judgment in interpreting and adapting guidelines such as policies, regulations, and accreditation standards for application to specific situations.
• Assignments are usually long-term, recurring, or broadly defined, with objectives, priorities, and deadlines provided for new tasks.
• Selects methods and solves most problems independently; completed work is evaluated for technical soundness, appropriateness, and conformity to professional standards.
• Maintains contact with other federal departments, state or local government officials, and external stakeholders to explain, coordinate, and interpret policies and programs.