Education and Work Experience:

• Bachelor's Degree in Nursing (BSN): Preferred
• Nursing experience: Preferred

Licenses/Certifications:

• Registered Nurse (RN) licensure in the state of practice: Required
• Cardiopulmonary Resuscitation (CPR) or Basic Life Support (BLS OR HS-BLS OR RQIBLS) certification: Required

Essential Functions:

• Supports the development and implementation of existing risk management, quality/regulatory programs to be consistent with established philosophies/procedures of the organization. Reviews/analyzes reports to evaluate event severity and identify potential system/process deficits via exercising critical thinking skills and clinical judgment. Assesses completeness of relevant information in incident reports, and performs review of corresponding medical charts, as necessary to determine report ability according to regulatory criteria and clinical interpretations.
• Coordinates and assures efficient/effective quality review and data management. Evaluates practice patterns, interventions, outcomes and regulatory compliance. Prepares case summaries and timelines with the goal of identifying proactive risk reduction opportunities to improve patient care and mitigate legal/regulatory risks. Collaborates with the hospital-wide Accreditation Tracer Program for activities that aim for risk reduction/prevention in clinical practice and the care environment.
• Creates aggregate reports as assigned for trending incident types, severity, and preparing action/resolution proposals based on emerging issues via facilitating discussions with relevant department leaders. Develops education strategy/content aiming to mitigate legal risks associated with practice/environmental safety gaps for optimal patient safety, clinical outcomes and regulatory compliance. Implements a safe plan of care for patients of varying complexity given years of experience.
• Analyzes information, reaches decisions, takes appropriate action and follows through, based on review of incident reports, legal case investigation and hospital-wide risk/compliance-related aggregated data. Utilizes electronic medical record to identify co-morbidities, complications and compliance with hospital policies/procedures, as well as community standards of care. Contributes to better understanding/interpretation of criteria for case review. Acts as a technical subject matter expert in own and possibly related discipline(s). Has substantial understanding of techniques, processes, procedures to perform the job and seeks to complete tasks in creative and effective ways.
• Participates in national databases submission via evaluating practice patterns, interventions, outcomes and regulatory compliance. Leads in preparing case summaries, timelines and initial Root Cause Analysis (RCA) for complicated cases with the goal of identifying proactive process changes. Runs program(s) with moderate budget/impact.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.