JOB SUMMARY: Professional RN position in a hospital setting that facilitates the quality improvement efforts of the organization. Assists in the development, planning, and implementation of the organization quality program. This includes developing and managing processes related to quality improvement, compiling data from various sources into meaningful information to be used to support quality initiatives and coordinating the release of data to external agencies and vendors. Supervises clinical review coordinates.

EDUCATION, EXPERIENCE, TRAINING
1. Associate or Bachelor’s degree in nursing required.
2. Minimum five years experience in an acute care hospital setting including a working knowledge of quality and peer clinical review processes, accrediting standards, regulatory requirements, and performance improvement methodologies.
3. Computer skills including word processing, spreadsheet, data base and graphics programs.
4. CPHQ preferred or retained within two years of hire date.

DUTIES AND RESPONSIBILITIES
1. Assists director in coordinating quality activities.
2. Acts as consultant/resource regarding quality issues.
3. Compiles and reports trends of quality activities.
4. Assists in quality related policies and procedures.
5. Assists in supplying internal and external benchmarking data.
6. Participates in annual review of effectiveness of quality plan.
7. Serves as a member of hospital committees that pertain to quality as required.
8. Assures compliance with regulatory agencies as related to quality.
9. Communicates requirements and standards changes in a timely manner.
11. Coordinates and oversees quality organization for medical staff quality committees.
12. Participates in local/state/national organizations regarding quality.
13. Performs preliminary reviews and data abstraction from medical records.
14. Designs and implements medical staff quality studies.
15. Analyzes data and identifies opportunities for improvement.
16. Presents reports and participates in assigned section, committee, and department meetings.
17. Keeps up to date with current regulations and standards related to duties.
18. Serves as one of the HARP Administrators along with Director of Quality and Risk.
19. Facilitates and develops Quality related education for employees and medical staff.
20. Serves as Performance Improvement Joint Commission Chapter Champion for Joint Commission Readiness Team.
21. Completes STS/CABG data submissions.
22. Serves as Truven Core Measures Administrator.
23. Facilitates compliance with Core Measures abstraction accuracy and assists with achieving facility core measure and clinical VBP Goals.