Quality Improvement Specialist - Quality Administration

Position Status:

Full time

Shift:

First Shift (Days - Less than 12 hours per shift) (United States of America)

Hours per week:

40

Job Information
Exemption Status: Exempt

A Brief Overview
Responsible for the collection, analysis and reporting of data and the communication of outcomes, gaps in care and opportunities for improvement with a focus on the organizational goals and objectives that lead to improved patient outcomes.

Education Qualifications

• Associate's Degree Nursing. Required
• Bachelor's Degree Nursing. Preferred

Experience Qualifications

• 3 years Clinical experience. Required
• Computer and Internet skills and experience required – familiarity and comfort with MS Office products is essential for success in this position (Word, Excel, and PowerPoint). Required
• Clinical chart review and abstraction experience. Preferred
• Database data entry experience. Preferred
• Quality improvement of patient safety knowledge and experience. Preferred

Skills and Abilities

• Knowledge of statistics. (Preferred proficiency)

Licenses and Certifications

• Registered Nurse - KSBN Required
• Certified Professional In Healthcare Quality - HQCC Preferred

What you will do

• Analyzes data, conducts in-depth process reviews with stakeholders to identify opportunities to improve quality outcomes. Identifies challenges and barriers to performance improvement and works collaboratively to find successful solutions. As a subject matter expert, provides evidence based, best practice guidance to facilitate promotion of positive patient outcomes, educates stakeholders on quality measures, gaps in care delivery and opportunities for process improvement (including hospital and clinic staff, physicians, departmental Directors).
• Responsible for the compilation and analysis of data which supports quality and performance improvement in order to fulfill regulatory and payer- based commitment. These programs include but are not limited to: the hospital acquired condition reduction program (HACRP) , Value Based Purchasing, Hospital Inpatient Quality Reporting Program, Hospital Outpatient Quality Reporting Program, Ambulatory Surgery Center reporting program, Readmission and Mortality programs, Healthcare Associated Conditions, National Health Safety Network, NSQIP, MBSAQIP, MIPS, BCBS ACO, MSSP ACO and others.
• Enters information into national registries and databases as determined by the organization with accuracy and efficiency. Team members assigned to the MBSAQIP registry will review full details of the MBSAQIP standards, complete online initial training as well as ongoing maintenance of training certification, must attend at least two of the three required MBSAQIP meetings one of which must be the annual comprehensive review meeting, retrieves and enters long-term follow-up data on all patients, maintains confidentiality of PHI, and routinely communicates directly with the MBS Director.
• Develops and maintains a collaborative relationship with the key clinical and hospital areas associated with the assigned databases, attending relevant meetings, providing updates on quality improvement outcomes, education and support.
• Effectively utilizes the hospital medical record system in the concurrent, reliable collection of quality program components.
• Utilized exceptional communication skills to convey variances and fallout in quality compliance with members of the hospital and clinic community. Works with staff to conduct root cause analysis to identify underlying issues and opportunities for improvement.
• Utilizes organizational skills to maintain efficient and timely workflow.
• Participates in interviews/surveys regarding this area of expertise as requested by management.
• Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into databases and websites in a timely manner.
• Collaborates with leadership to assist with establishing and achieving specific organizational objectives.
• Serves as an educational resource by developing educational material and delivering presentations.
• Attends conferences and webinars pertaining to the program to stay current and informed.

Required for All Jobs

• Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
• Performs other duties as assigned

Patient Facing Options

• Position is Not Patient Facing

Remote Work Guidelines

• Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.
• Stable access to electricity and a minimum of 25mb upload and internet speed.
• Dedicate full attention to the job duties and communication with others during working hours.
• Adhere to break and attendance schedules agreed upon with supervisor.
• Abide by Stormont Vail’s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.

Remote Work Capability

• Hybrid

Scope

• No Supervisory Responsibility
• No Budget Responsibility No Budget Responsibility

Physical Demands

• Balancing: Occasionally 1-3 Hours
• Carrying: Occasionally 1-3 Hours
• Climbing (Stairs): Rarely less than 1 hour
• Crouching: Rarely less than 1 hour
• Driving (Automatic): Rarely less than 1 hour
• Eye/Hand/Foot Coordination: Frequently 3-5 Hours
• Feeling: Occasionally 1-3 Hours
• Grasping (Fine Motor): Occasionally 1-3 Hours
• Grasping (Gross Hand): Occasionally 1-3 Hours
• Handling: Occasionally 1-3 Hours
• Hearing: Frequently 3-5 Hours
• Kneeling: Rarely less than 1 hour
• Lifting: Occasionally 1-3 Hours up to 50 lbs
• Pulling: Occasionally 1-3 Hours up to 50 lbs
• Pushing: Occasionally 1-3 Hours up to 50 lbs
• Reaching (Forward): Occasionally 1-3 Hours up to 50 lbs
• Reaching (Overhead): Rarely less than 1 hour up to 50 lbs
• Repetitive Motions: Frequently 3-5 Hours
• Sitting: Frequently 3-5 Hours
• Standing: Occasionally 1-3 Hours
• Stooping: Rarely less than 1 hour
• Talking: Frequently 3-5 Hours
• Walking: Occasionally 1-3 Hours

Working Conditions

• Noise/Sounds: Rarely less than 1 hour

Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment.

Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.