Quality Nurse

Overview

The Quality Nurse identifies deceased patient medical records from assigned hospitals within LiveOnNY’s Designated Service Area (DSA) that meet established criteria for review. The Quality Nurse reviews and assesses deceased patient records for missed organ and tissue donation potential, evaluates referral timeliness, and supports LiveOnNY’s internal audit program through donor and non-donor record reviews. The role collaborates with LiveOnNY departments to support high-quality practices and ongoing performance improvement. Clinical functions are limited to record review and audit; this role does not provide direct patient or donor care or make donor-suitability or recovery decisions.

For all assigned reviews, the Quality Nurse problem-solves, communicates findings, and reports identified barriers or issues to the appropriate LiveOnNY department or leadership. The Quality Nurse supports and fosters the mission of the organization and its commitment to organ, eye, and tissue donation. The Quality Nurse Lead provides day-to-day functional oversight of assigned reviews; the Senior Director of Quality retains personnel supervision.

All services performed in this role must be conducted in compliance with applicable federal and state laws, regulations, and oversight requirements, including but not limited to CMS, New York State, FDA, OPTN, and all applicable LiveOnNY policies, standard operating procedures (SOPs), and work instructions.

NON-EXEMPT POSITION – PROFESSIONAL TIME AND OUTSIDE WORK:

The Quality Nurse shall devote all time worked for LiveOnNY exclusively to the duties and responsibilities of the position.  The Quality Nurse shall not perform work for another employer, client, or business during LiveOnNY work time.  The Quality Nurse shall disclose outside employment, consulting, business activities, and other professional commitments in accordance with LiveOnNY’s Conflicts of Interest Policy.

Responsibilities

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

Death Record Review

• Facilitates requests to hospitals for a complete list of all hospital deaths for a specified time period.
• Identifies deaths requiring review to assess whether donation referral criteria were met.
• Reviews and assesses deceased patient records to determine whether donation referral criteria were met.
• Accurately completes and submits record review documentation.
• Maintains accurate data and status reports on complete and pending reviews.
• Reports the status of reviews to departmental leadership and populates reports for communication of findings.
• Establishes and maintains effective working relationships with Medical Records Departments and other stakeholders in service area hospitals.
• Consistently demonstrates initiative to continuously improve reporting accuracy and timeliness.
• Tracks and trends pertinent metrics and communicate data in a clear and meaningful manner.

Record Review for Internal Audit

• Conducts reviews of hospital medical records for non-donors to determine the date and time at which clinical triggers for organ donation referral were met and completes required documentation.
• Conducts assigned audit of donor and non-donor records in support of organizational internal audits.
• Assists with the review of donor and non-donor records to identify opportunities for improvement that may increase organ recovery and populates reports for communication of findings to departmental leadership.

Quality, Performance Improvement, and Professional Conduct

• Assists departmental leadership and executive staff with performance improvement efforts.
• Demonstrates respect, patience, and professionalism in all interactions with customers and co-workers.
• Takes initiative and participates in continuous quality and process improvement activities consistent with organizational expectations.

Technical Proficiency & Documentation Systems

• Utilizes LiveOnNY electronic donor record systems and other communication systems and applications, and related documentation tools to manage workflow.
• Ensures accurate and timely data entry in accordance with LiveOnNY SOPs and regulatory standards.

Compliance and Documentation

• Maintains complete and accurate documentation of assigned death record reviews, internal audits, and related quality activities.
• Performs assigned review and audit responsibilities in accordance with applicable CMS, OPTN, NYS AGA, FDA, and LiveOnNY requirements.
• Participates in QAPI reviews, case reviews, audits, and performance improvement initiatives as assigned.
• Maintains confidentiality consistent with LiveOnNY policies and standards.

Professional Conduct

Exhibits and maintains professionalism in high-stress and time-sensitive environments.

Exercises sound clinical judgment within assigned death record review and internal audit responsibilities.

Escalates complex or ambiguous clinical, regulatory, and/or ethical situations to leadership immediately.

Other duties may be assigned.

Qualifications

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

REQUIRED:

• Current Registered Professional Nurse (RN) license in the State of New York.
• Bachelor’s degree in Nursing from an accredited college or university.
• Minimum of two years of experience working with electronic medical records (EMRs), including chart review and medical record data abstraction.
• Must have knowledge of medical terminology, anatomy, and physiology.
• Ability to research information, draw conclusions, and make recommendations.
• Proficiency with common computer applications, including word processing, Excel, and PowerPoint.
• Strong interpersonal, verbal, and written communication skills.

PREFERRED:

• ICD-10 coding experience.
• Two years of critical care experience (ICU, ED, or OR) in a hospital setting.
• Previous quality assurance/performance improvement (QA/PI) experience.
• Experience with transplant patients or critically ill neurological patients.
• Knowledge of or experience with process improvement fundamentals (Lean, Six Sigma, PDSA, RCA).

ADDITIONAL REQUIREMENTS:

Monday to Friday, however weekends and evenings as part of an on-call rotating schedule based on Departmental needs may be required.

PHYSICAL DEMANDS:

• The Quality Nurse performs most duties while seated at a designated workstation, with occasional standing and walking.
• The Quality Nurse frequently uses a keyboard, mouse, and other work devices, requiring repetitive movement of the hands, wrists, and fingers.
• The Quality Nurse regularly speaks and listens during telephone or headset conversations.
• The Quality Nurse uses close vision to read and process text, numbers, and data on computer screens.
• The Quality Nurse may occasionally be required to lift or move up to 15 pounds.
• Uses reliable transportation in order to travel throughout LiveOnNY’s DSA and, when required, outside the DSA.
• Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

LICENSES:

Regarding any licensure, certification, or other credentials required or preferred by LiveOnNY, LiveOnNY requires they be maintained and current without any infractions or issues.  The Quality Nurse understands that the Quality Nurse is responsible for maintaining all qualifications, licenses, certifications, competencies, and other requirements applicable to this position throughout the Quality Nurse’s employment and for successfully completing all required education, training, competency assessments, and continuing education required by LiveOnNY.

LiveOnNY offers a competitive salary & comprehensive benefits package.

403(b) deferred annuity

Medical/Vision/Dental

Tuition reimbursement

Paid time Off

Pet Insurance

Life Insurance

Short and Long Term Disability Insurance

Salary Range: $110,000 - $130,000