BASIC PURPOSE OF THE JOB

Conducts concurrent and retrospective criteria-based monitors using established policies and procedures by reviewing medical records, abstracts, computer records, etc., for a variety of data. Under the supervision of the Quality Management Director assists in managing the Hospital-wide occurrence monitoring program. Act as a resources to all medical and Hospital departments for quality assurance. Maintains the strictest confidentiality of all patient information reviewed. Promotes the concept of cooperation and develops open lines of communication with department employees, patients, visitors and other personnel within and outside the Hospital.

REPORTS TO

• Director—Quality Management

JOB REQUIREMENTS

Supervisory Responsibilities: No

Minimum Education: Bachelors Required

Degree: Degree in Nursing, Health Care Administration, Public Health, Health Information Management or other related field OR Minimum Work Experience: Minimum of 3 years of clinical nursing practice, in an acute hospital setting or three years of experience in quality assessment required.

License/Certification Required: RHIA or CPHQ

Minimum Work Experience: Minimum of 3 years of clinical nursing practice, in an acute hospital setting or three years of experience in quality assessment required.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of clinical practice with ability to interpret clinical information.
• Must possess excellent verbal and written skills in order to communicate pertinent information appropriately to various levels of professional hospital staff.
• Proficient in MS Office (specifically Word, Excel, PowerPoint) and data base technologies.

DUTIES AND RESPONSIBILITIES

• Accurately and proficiently reviews clinical information both concurrently and retrospectively for use in a variety of quality improvement activities as required by the Hospital’s PI plan, Joint Commission standards and third party payor regulations.
• Documents occurrence screens and other information in on-line system, accurately, timely and with critical analysis to question or address inconsistencies or concerns.
• Queries/writes reports from clinical data bases such as CHCA,PHIS, Medisolv, Meditech, QRM and monitors database accuracy.
• Demonstrates strong abilities in compiling, analyzing summarizing and displaying data for review.
• Initiates performance case review for department specific indicators, occurrence screens, etc.
• Ensures timely completion of all review assignments, reports any deviations in completion schedule.
• Identifies the need and develops data collection tools for criteria based monitors.
• Willingly performs additional focused reviews and specific studies as requested to support the Hospital’s PI activities.
• Interacts and intervenes with multidisciplinary health care teams as a facilitator in a purposeful goal directed fashion, including proactive risk analysis.
• Pro-actively assesses the need for, develops and conducts training relevant to Quality Management and Patient Safety improvements.
• Continually shows commitment to the Department by extending self when need arises.
• Maintains a consistent flexibility to the work assigned, accepting interruptions, or priority urgent requests professionally.
• Consistently optimizes time efficiently and effectively, and serves as a role model/resource for others.
• Consistently utilizes appropriate tools, techniques, resources/systems to achieve maximum results and teaches others to do so.
• Is viewed as a resource in department when dealing with issues of systems and resources and accomplishing tasks in the most efficient and effective ways.

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Light lifting, pushing and pulling is required for 1-20 lbs occasionally and frequent moving of objects of less than 10 lbs is required. Frequent sitting with some walking, standing, squatting, bending, and reaching is required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday.