Summary
SUMMARY: The Diagnostic Imaging Education, Quality & Informatics Administrator is a key member of the Diagnostic Imaging leadership team, responsible for providing strategic oversight of department-wide education, clinical competencies, quality assurance, regulatory compliance, PACS/RIS workflow support, and radiologic student training programs. This role plays a critical part in ensuring continuous regulatory readiness for agencies such as the American College of Radiology (ACR), The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and the California Department of Public Health – Radiologic Health Branch (CDPH-RHB).
The Diagnostic Imaging Education, Quality & Informatics Administrator leads accreditation cycles, manages clinical competency validation across all imaging modalities, oversees departmental quality reporting, and coordinates PACS exception resolution and Epic RADIANT training. In addition, the role supports development and implementation of standardized documentation, safety protocols, and workflow education to enhance operational consistency and compliance.
Strong project management and process improvement skills are essential in this role. Project Management Professional (PMP) and/or Lean Six Sigma certification (Green Belt or higher) is strongly preferred to support the successful execution of cross-functional initiatives focused on increasing efficiency, reducing variation, and improving quality outcomes across the imaging service line.
The Administrator reports to the Imaging System Director and actively collaborates with the site managers to align strategies, participates in department leadership and staff meetings, prepares and presents agenda items, and represents Diagnostic Imaging in interdepartmental initiatives involving IT, Quality, Education, Compliance, and Regulatory Affairs.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
1. Leadership & Departmental Representation
Serve as an active member of the Diagnostic Imaging leadership team; contribute to strategic planning, department initiatives, and service line decision-making.
Participate in department leadership and all-staff meetings; prepare agenda items, present educational and quality-related updates, and follow up on assigned actions.
Represent the Imaging Department in systemwide committees, working groups, and forums related to IT, Quality, Education, and Regulatory Readiness.
Collaborate with operational leaders and radiologists to promote patient-centered care, imaging safety, and regulatory compliance across campuses.
2. Accreditation & Regulatory Readiness
Lead and coordinate all ACR accreditation processes for Diagnostic Imaging, including new submissions, renewal applications, clinical image uploads, documentation tracking, and correspondence with ACR reviewers.
Serve as the point of contact for ACR surveys, follow-up activities, and imaging quality sample submissions.
Ensure continuous regulatory readiness for TJC, CMS, and CDPH-RHB audits through structured internal monitoring, policy alignment, and staff preparation.
Lead departmental compliance with TJC Environment of Care (EOC) elements, maintain EOC documentation, and represent the department at monthly system EOC meetings.
3. Quality Assurance & Performance Improvement
Design and manage the Imaging Services Quality Assurance and Performance Improvement (QAPI) program, ensuring coverage of all modalities and sites.
Collect, monitor, and analyze quality data including CT QA logs, radiation dose tracking, Trophon disinfection reports, physicist surveys, and safety audits.
Coordinate internal quality reviews with modality leads and radiologists to drive continuous improvement and ensure clinical best practices.
Guide policy development, technical protocol standardization, and corrective action plans related to imaging safety and quality standards.
4. Education & Competency Oversight
Develop, implement, and track annual competencies, skill validations, and in-service education requirements for imaging staff across all modalities.
Provide ongoing training on PACS workflows, documentation standards, compliance topics, and best practices in image quality and patient safety.
Maintain department education calendars, sign-in logs, and audit-ready training documentation.
Coordinate Epic RADIANT workflow education and serve as credentialed trainer or backup, collaborating closely with IS/IT and Radiology Informatics.
5. Radiologic Student Program Leadership
Manage the clinical student training program for diagnostic imaging; oversee onboarding, site assignment, evaluations, academic affiliation agreements, and preceptor coordination.
Ensure program compliance with educational standards and state/federal guidelines; maintain student records, licensure verification, and competency completion logs.
Foster strong partnerships with academic institutions and support student integration into clinical teams.
6. PACS Exception Support & Imaging Informatics
Oversee and resolve imaging data issues within PACS, including study corrections, duplicate exams, incorrect labeling, and incomplete documentation.
Collaborate with radiologists, technologists, and IT to ensure data accuracy and imaging availability for diagnostic review and recordkeeping.
Participate in IS/IT meetings related to PACS system upgrades, workflow integration, and Epic RADIANT optimization projects; represent imaging operational needs.
Train staff on PACS documentation workflows and provide education on data quality and downstream impacts on billing, quality reporting, and accreditation.
7. Data Analytics, Reporting & Standardization
Develop and maintain dashboards, quality scorecards, and performance reports to track metrics across regulatory, operational, and clinical domains.
Use descriptive statistics and data visualization tools to evaluate trends, benchmark performance, and support department planning efforts.
Standardize QA definitions and documentation practices across sites, support data submissions for public reporting and accreditation surveys.
8. Other Duties as Assigned
Perform imaging procedures within the scope of licensure (up to 20% of the time) to maintain clinical competency, support staff development, and assist with operational coverage as needed.
Participate in organizational and departmental strategic initiatives, including cross-functional projects, performance improvement efforts, and priority deliverables assigned by the Imaging Director or executive leadership.
Support the preparation and execution of IS, regulatory, and compliance activities by assisting with documentation management, internal audits, and communication with vendors or external partners.
Fulfill additional responsibilities that advance departmental operations, regulatory readiness, or organizational goals. This may include leading or supporting special projects, addressing urgent staffing or compliance needs, contributing to systemwide initiatives, or responding to emergent situations requiring education, quality oversight, or clinical support. Flexibility, collaboration, and adaptability are essential to ensure the continued success of the Diagnostic Imaging service line.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
MINIMUM QUALIFICATIONS:
Required Education: Associate or bachelor’s degree in radiologic technology, Health Sciences, Healthcare Administration, or a related field.
Preferred Education: Master’s degree in public health, Education, Healthcare Administration, or Health Informatics.
Required Experience: Minimum of five (5) years of progressive experience in multiple modalities in diagnostic imaging with additional focus on education, quality, accreditation, or PACS operations.
Preferred Experience: Experience managing ACR accreditation, radiologic student programs, and compliance audits; participation in leadership committees or cross-functional teams.
Required Licenses/Certifications:
California Radiologic Technologist License (CRT)
ARRT Certification (R) & (CT)
California Fluoroscopy Permit
Basic Life Support (BLS) Certification
Credentialed EPIC trainer (or achieved within 90 days of hire)
Preferred Licenses/Certifications:
NMTCB, ARDMS, ARMRIT or additional ARRT Modality Certifications
Certified PACS Associate (CPAS), Certified DICOM Integration Professional (CDIP), and/or Certified PACS System Analyst (CPSA).
Project Management Professional (PMP) certification and/or Lean Six Sigma certification (Green Belt or higher) are strongly preferred to support process improvement and operational efficiency initiatives.
The pay range for this position reflects the base pay scale for the role at Alameda Health System. Final compensation will be determined based on several factors, including but not limited to a candidate’s experience, education, skills, licensure and certifications, departmental equity, applicable collective bargaining agreements, and the operational needs of the organization. Alameda Health System also offers eligible positions a generous comprehensive benefits program.