Quality Nurse Coordinator

AHMC HealthCare; San Gabriel (CA); On-site; USD 90,000 - 130,000; Full time

Job summary

San Gabriel Valley Medical Center seeks an experienced nurse data abstractor to support clinical quality reporting. The role requires active participation in regulatory compliance, CMS/The Joint Commission reporting, and performance improvement initiatives across the hospital.

The ideal candidate holds California RN licensure with a nursing degree and a background in risk management or performance improvement, plus strong analytical and teaching skills to support hospital committees and PI

Qualifications

• Knowledge of regulatory and accreditation standards applicable to hospitals.
• Ability to design meaningful presentations for diverse audiences.
• Collaboration with staff to reduce risks and improve performance and safety.
• Ability to teach across organizational levels.
• Expertise in medical record abstraction criteria.
• Familiarity with Quality Improvement methodologies.
• Strong medical terminology and formulary/pharmacology familiarity.
• Proficient computer skills in standard software.
• Understanding of formulary drugs and pharmacological indications.

Responsibilities

• Performs review, investigation and analysis of occurrences and cases identified through reporting and screens.
• Coordinates internal departments and external entities to ensure regulatory compliance.
• Formulates professional data reports and presentations for hospital committees.
• Understands abstraction components and inclusion/exclusion criteria.
• Completes patient data entry accurately within established timeframes.
• Analyzes data to identify trends and support quality improvement.
• Generates physician quality reports for OPPE, PPE purposes.
• Maintains daily operations of the PI department.

Skills

Regulatory standards

Presentation design

Risk management collaboration

Teaching

Medical record abstraction

Quality improvement

Medical terminology

Computer skills

Pharmacology knowledge

Education

Registered Nurse license in California

Bachelor's degree in Nursing

Bachelor's degree in Healthcare-related field

Master's degree or higher

Job description

• Facilitates, in collaboration with the Manager of Quality Management accurate, timely and consistent clinical data to public reporting databases and agencies, including The Joint Commission (Oryx), and CMS. Reviewing paper and electronic medical records, interpreting, analyzing medical record documentation, and extrapolating pertinent health information needed for determining clinical quality and core measures required by The Joint Commission, CMS and other clinical reporting programs. Accurately entering the data directly into our electronic data collection database. Researching all available resources on missing, conflicting or ambiguous information in the medical record. Applying skilled judgment in determining that deviations from these guidelines may indicate an omission or inaccuracy within the patient's medical record.
• This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center's strategic plan and the goals and direction of the Performance Improvement Plan (PIP).

• Facilitates, in collaboration with the Manager of Quality Management accurate, timely and consistent clinical data to public reporting databases and agencies, including The Joint Commission (Oryx), and CMS. Reviewing paper and electronic medical records, interpreting, analyzing medical record documentation, and extrapolating pertinent health information needed for determining clinical quality and core measures required by The Joint Commission, CMS and other clinical reporting programs. Accurately entering the data directly into our electronic data collection database. Researching all available resources on missing, conflicting or ambiguous information in the medical record. Applying skilled judgment in determining that deviations from these guidelines may indicate an omission or inaccuracy within the patient's medical record.
• This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center's strategic plan and the goals and direction of the Performance Improvement Plan (PIP).

KNOWLEDGE OF WORK

• Demonstrates current knowledge of regulatory/accreditation standards, hospital policies and procedures and medical staff by laws.
• Assists with design of presentations which are meaningful to intended audience.
• Provides feedback and collaborates with staff in the effort to eliminate risks and improve performance and safety.
• Demonstrates ability to teach effectively to all levels of the organization.
• Demonstrates skills in Medical Record review specific to abstraction criteria.
• Demonstrates the ability to apply Quality Improvement methodology.
• Thorough understanding of medical terminology.
• Demonstrated computer skills.
• Thorough understanding of formulary drugs and pharmacological indications.

SPECIFIC JOB DUTIES

• Performs review, investigation and analysis of occurrences and cases identified through occurrence and cases identified through occurrence reporting, generic screens, etc, meeting criteria for peer review.
• Coordination of internal departments and external entities to ensure compliance with company policies, and State/Federal Regulatory and Accreditation standards.
• Ability to formulate professional data reports and presentations for hospital committees and physician specialty groups.
• Understands abstraction components, both inclusion and exclusion criteria, specific to measurements.
• Adheres to established guidelines for criteria abstractions.
• Completes patient data entry accurately and within established timeframes.
• Analyzes data, both on aggregate and patient level as needed, to identify trends as well quality improvement.
• Understands the Department goals of strong results in the following programs/initiatives Truven Top 100 hospital recognition, Leap Frog, CMS star rating, no penalties with HAC program.
• Maintains regular updates of policies and procedures.
• Performs medical record reviews associated with QI; analyzes data collected for QI projects; tracks, trends and prepares information to submit to appropriate committees
• Involvement in the daily operations of the department to include PI database management; case review involving Patient Safety and Core Measures.
• Generate ongoing physician specific quality reports including tracking and trending of peer reviews and for OPPE, PPE purposes.
• Performs other duties as assigned or required by the immediate supervisor or Administration.

EDUCATION/TRAINING/EXPERIENCE

Requires either (1) Registered Nurse license in the state of California with a bachelor's degree in Nursing; or (2) Bachelor's degree in a Healthcare-related field; (3) Master's Degree or higher education

Strong clinical background and broad knowledge base preferred

Excellent verbal and written communication and computer skills

Strong analytical and problem solving skills

Knowledge of quality improvement processes and techniques

Two (2) to three (3) years' experience in Performance Improvement or Risk Management, Preferred

LICENSES/CERTIFICATIONS

Current California RN License