RN QUALITY MANAGER (FT 32 HRS.) 0QM01

Penobscot Valley Hospital; Lincoln (ME); On-site; USD 54,000 - 76,000; Full time

Benefits offered by this job

Section 125 Cafeteria Plan

Partial health insurance subsidy

403(b) plan

Job summary

Penobscot Valley Hospital seeks a dedicated Quality Improvement professional to support the hospital-wide QI plan and ensure regulatory compliance. You will collaborate with the QI team and departments to manage data collection, analysis and reporting for CMS measures.

The role emphasizes advancing patient safety and service excellence through training, data tools, and ongoing education aligned with Joint Commission, CMS and CDC standards.

Qualifications

• Experience in hospital or clinic quality improvement programs.
• Knowledge of regulatory standards (Joint Commission, CMS, CDC).
• Ability to collect, analyze and display data for improvement.

Responsibilities

• Assist in implementing the hospital-wide Quality Improvement Plan per regulatory standards.
• Monitor and evaluate quality measures and data changes.
• Coordinate data collection, submission and reporting for CMS measures.
• Support QI teams with data collection, analysis and reporting.
• Provide staff training and facilitate QI processes and methodologies.

Skills

Quality Improvement

Regulatory compliance

Data analysis

CMS reporting

Education

RN license

Tools

MS Excel

Job description

Description

0QM01

This is a full-time, salaried position scheduled for 32 hours per week.

JOB FUNCTIONS

Responsibilities:

• In collaboration with QI department team, assist in the implementation of the hospital-wide and Rural Health Clinic Quality Improvement Plan in accordance with standards set forth by regulatory agencies including but not limited to:
• The Joint Commission
• CDC
• Centers for Medicare and Medicaid Services (CMS)
• Community Care Partnership of Maine (CCPM )
• Monitor and evaluate any quality measure changes.
• Manage the publicly reported data process and internal requirements associated with publicly reported data.
• Coordinate the publicly reported data process including the collection, analysis, submission and reporting of CMS inpatient and outpatient measures.
• Work closely with departments during the data abstraction processes.
• Coordinate collaborative efforts to achieve hospital compliance with CMS core measure initiatives.
• Assist in the development and enhancement of data collection tools.
• Ensure regulatory compliance in all related activities and serve as resource for regulatory compliance.
• Provide support to clinical/operational quality improvement teams as assigned
• Facilitate QI teams, provide training and collaborate with team members in QI processes and methodologies.
• Provide staff support to teams (i.e. literature search, data collection, database maintenance, statistical analysis and data display methodologies).
• Write interpretive reports highlighting variations in clinical process and outcomes to identify improvement opportunities.
• Assist in the development and management of projects that employ a systematic method to identify, benchmark and integrate best demonstrated practices.
• Work with teams to identify and recommend process and documentation improvements.
• Supports the implementation and ongoing, organization wide, service excellence program as delegated.
• Participates in the implementation of ongoing education for leadership standards and employee standards of behavior.
• Monitors and reports patient experience data and collaboratively works with departments to develop action plans to enhance the patient’s experience based on established best practices.
• Fulfills identified tasks to sustain an organizational culture with a high focus on service excellence established tactics in all departments.
• Support physician peer review process related to quality-of-care reviews.
• Provide staff support to Committees that includes agenda and report preparation, maintain minutes, correspondence and follow-up on all action items.
• Ensure compliance with all regulatory agencies.
• Disseminate comparative clinical data that illustrates opportunities to reduce variation, improve outcomes and integrate best demonstrated practices.
• Perform routine chart reviews as defined by medical staff.
• Prepare individual physician profiles for periodic review including medical staff reappointment.
• Carry out the activities of the data management program as directed:
• Collect and validate data for identified key performance indicators per operational definitions for each metric.
• Compile and distribute reports per schedule.
• Utilize statistical tools for data presentation.
• Retrieve data from in-house electronic systems and other data sources to contribute.
• Participate in hospital-wide education on relevant quality improvement topics including New Staff and New Physician Orientation.
• Remain current on evidence-based practice and regulatory updates.
• Refer to hospital policy, accreditation standards and regulatory guidelines to guide recommendations or action plans.

Emergency/Disaster Management: As an employee of Penobscot Valley Hospital, the position has an inherent role to care for our community members when in need. To this regard, the incumbent will be expected to participate in emergency/disaster preparedness planning and drills as requested. When called upon during a real life disaster/emergency event, the incumbent will be expected to participate in the Hospital’s response to this event, within the scope of professional and personal ability to do so.

Requirements

Maine RN License, with 3 years’ experience in hospital or clinic setting. Quality improvement experience and computer skills preferred.

Benefits

PVH has a Section 125 Cafeteria Benefits Plan and pays a portion of the cost of our health plan, dental, basic life, and disability insurance for employees for 30+ authorized hours, and provides partial subsidy for dependent health insurance. Part-time employees are eligible to receive dental, life, and disability coverage and are eligible to participate in the health insurance plan. Other benefits include a 403(b) plan and earned time off accrual.