In collaboration with the clinical lead, provides analytical support and coordinates quality management and performance improvement processes related to quality assessment; performance improvement; clinical documentation review; risk management; infection prevention and control; patient safety; and/or accreditation, regulation and licensing. Under the guidance of a program director or manager, responsible for collecting and researching data, performing data analysis, providing recommendations on data collection/reporting and presenting results.
Essential Functions:
- Partners with clinical quality service lines to identify issues within operations for focus improvement efforts.
- In collaboration with the clinical lead, coordinates on-going, multiple projects (e.g., supporting the clinical service line model).
- Develops timelines and agenda items.
- Helps identify best methods and processes for performance improvement, including developing project plans, facilitating group process and training related to data collection/reporting.
- Support groups through the full rapid improvement cycle.
- Helps identify and recommend actions to correct activities and processes.
- Analyzes, interprets information and makes recommendations on data collection.
- Presents data in a graphical format to support leadership groups and committees strategic planning and decision-making.
- Analyzes and compiles data into spreadsheets and databases.
- Helps identify and communicate alternative solutions to projects as needed.
- Abstracts data using Health Connect; runs reports and communicates results of analysis effectively to key stakeholders.
- Maintains and coordinates audits.
- Assists with developing audit methods to assess performance improvement and to ensure regulatory compliance.
- Based on audit results, creates and presents reports using various systems and databases (e.g., MIDAS focus studies).
- Supports workgroups or committees (e.g., peer review).
- Prepares meeting materials, including agendas and minutes; coordinates conference room logistics; monitors and follows up with action plans).
Secondary Functions:
Assists in the coordination of the quality management/utilization management department activities with other medical center departments. Acts as a consultant for appropriate departments on quality management, utilization management and risk management activities. Assists with quality management studies through data collection, data input and report development. Provides objective assessment of important aspects of patient care through ongoing chart review with pre-established criteria. Reports all occurrences which may lead to medical center liability and follows up as necessary. Facilitates interdisciplinary collaboration for development of patient care paths. Reviews hospital admissions and extended stays for specific hospital departments. Serves as a member of the QM and/or UM Committees as needed. Attends and/or participates in committee meetings as needed. Assists in orientation and training of peers; in formulating and evaluating policies and procedures. Performs special projects as assigned, such as statistical reports for state, federal, and local agencies. Assists the director of quality and utilization management for QM and UM in the formulation of department goals and objectives.
Qualifications:
Basic Qualifications:
- Demonstrated ability in managing databases, developing reports and data analysis using Excel and Access (3-5 years).
- Bachelor's degree in business administration, information technology or health care related field OR equivalent experience.
- Demonstrated knowledge of quality improvement; accreditation and licensing.
- Strong problem solving, project management and teamwork skills.
- Advanced skills with Microsoft applications (Word, Excel, Access and Power Point).
- Must be able to work in a Labor-Management partnership.
Preferred Qualifications:
- 1 yr minimum experience with Trauma One or a similar trauma data base, AIS coding, ICD-9 Coding.
- A minimum of one (1) year experience in quality management with demonstrated knowledge of quality improvement, statistical analysis, accreditation and licensing processes preferred.
- Strong problem solving, projectmanagement, group facilitation and teamwork skills.
- Demonstrated ability to assess or evaluate patient medical records as it relates to quality of care and systems analysis for the trauma
patient.
- Current working knowledge of The Joint Commission, NCQA and Title 22 standards/regulations.
- Supervisory experience preferred. Demonstrated knowledge of adult learning theories.
-PC literate, Microsoft Office applications preferred.
- Valid CA driver's license with personal means of transportation preferred.
- Preferred: Additional certification in trauma registry (CSTR) and AIS severity coding (CAISS); if no
trauma registry experience, employee will sit for both exams after two (2) years experience in the role. Additional working knowledge and/or experience with trauma verification survey process, trauma center organization, and trauma research is preferred.
- ACS trauma registrar course.
- Bachelors Degree - Nursing.
- Skills Testing: Microsoft Office (Word & Excel - Intermediate).
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.