Supports the effective execution of quality improvement plan program activities for assigned medical staff services and departments. Guides the medical staff in the areas of interpretation of regulatory and licensing requirements and interpretation and implementation of quality improvement processes. Coordinates the development of quality improvement indicators.Prepares Chiefs and Chairs for all surveys. Work is overseen by the Coordinator or Director.
Essential Functions:
- Facilitates meetings regarding certain issues or agenda items for the purpose of maintaining the licensing and accreditation requirements
- Conducts reviews utilizing medical staff and multidisciplinary criteria/guidelines/indicators
- Determines which cases fail to meet the criteria and require further multidisciplinary review
- Executes the quality improvement monitoring agenda for assigned departments to include all aspects of data management and analysis of trends and patterns of practice
- Serves as a resource regarding regulatory and organizational requirements
- Assures that activities related to the quality improvement process will meet the federal, state and local standards and requirements
- Serves as a liaison between the medical staff, ancillary support departments and QI department members
- Ensures confidentiality of information
- Provides information to physician profiles based on quality of care and focus reviews
- Compiles information and prepares quarterly reports
- Coordinates the development of meaningful quality improvement indicators that comply with organizational guidelines and regulatory requirements
- Conducts statistical analysis to determine data reliability and confidence intervals
- Assists in evaluations for assigned areas and coordinates approval
- Updates Quality Improvement Plan and coordinates approval
- Develops and implements systems, procedures and forms to improve data collection, management and display and to aid in the education of new processes or changes in standards of practice
- Completes special projects, studies and related statistical analysis
Qualifications:
Basic Qualifications:
- Previous experience, usually two (2) - three (3) years in either a medical staff or quality improvement function
- Bachelor's degree in a health related field preferred
- Medical Terminology certification preferred
- ART, RRA or LVN preferred
- Certified Medical Staff Coordinator preferred
- Significant knowledge of TJC, Title 22, NCQA and CMA standards and requirements, TQM and tools for indicator development and display
- Broad working knowledge of medical care practice and procedures including familiarity with medical records and chart review
- Strong statistical and data management skills
- Ability to analyze and summarize complex clinical situations
- Proficient with software used in the department
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.