Stroke & Sepsis Quality Program Lead

Three Crosses Regional; Las Cruces, Northern (NM, KY); Hybrid; USD 70,000 - 100,000; Full time

Job summary

Three Crosses Regional Hospital in Las Cruces, NM seeks a Quality Stroke & Sepsis Coordinator (FT) to lead hospital programs, ensure evidence-based care, and maintain compliance with accreditation and regulatory requirements. The role partners with physicians, nursing, emergency services, and Quality leadership to drive performance improvement, education, and timely reporting.

RN licensed professionals with 3+ years of acute care are encouraged to apply.

Qualifications

• RN license required.
• Associate degree in nursing is required.
• BSN preferred.
• Minimum 3 years of hospital or acute-care nursing experience.

Responsibilities

• Serve as the primary coordinator for Stroke and Sepsis programs, ensuring compliance with applicable certification standards, regulatory requirements, clinical guidelines, and performance measures.
• Leads Stroke certification and Sepsis program readiness activities, including documentation review, gap analysis, action planning, tracers, and follow-up monitoring.
• Attends Stroke and Sepsis activations when on duty to observe the clinical response, promote adherence to established protocols, and identify opportunities for improvement.
• Provides timely, constructive feedback and real-time education to physicians, nurses, and other members of the care team following clinical activations and case reviews.
• Coordinates and performs accurate clinical data abstraction, validation, entry, and submission for Stroke and Sepsis measures, registries, and required reporting platforms.
• Reviews medical records and supporting documentation to evaluate compliance with clinical pathways, treatment timeframes, documentation requirements, and established standards of care.
• Monitors clinical performance measures and outcomes, including treatment timeframes, bundle compliance, complications, mortality, transfers, readmissions, and other established indicators.
• Analyses performance data and identifies trends, barriers, and opportunities for clinical and operational improvement.
• Prepares reports, dashboards, case summaries, and performance updates for hospital leadership, medical staff, committees, clinical departments, and accreditation review.
• Conducts and participates in case reviews, tracers, focused audits, and other performance-improvement activities related to Stroke and Sepsis care.
• Collaborates with physicians, nursing leadership, emergency services, pharmacy, laboratory, radiology, respiratory therapy, informatics, education, and other departments to support timely, standardized, and coordinated care.
• Works with department leaders and frontline staff to develop, implement, and monitor corrective actions and performance-improvement plans.
• Develops and provides ongoing education and orientation for staff and providers regarding Stroke and Sepsis.
• Participates in the development, review, and revision of Stroke and Sepsis policies, protocols, clinical pathways, order sets, and educational materials.
• Coordinates Stroke and Sepsis committee activities, including meeting preparation, case presentation, data reporting, action-item tracking, and follow-up.
• Collaborates with the Quality Data Analyst and Quality leadership to ensure data accuracy, integrity, and alignment with certification and regulatory requirements.
• Maintains complete, organized, confidential, secure, and survey-ready program documentation, case files, educational records, and correspondence.
• Participates in Stroke certification surveys, program reviews, and required follow-up activities.
• Remains current with changes in certification standards, CMS requirements, evidence-based clinical guidelines, and applicable regulatory expectations.
• Serves as a resource to clinical teams and promotes a collaborative, nonpunitive approach to case review, education, and continuous improvement.
• Attends meetings, committees, and workgroups related to the Stroke and Sepsis programs, as assigned.
• Performs other duties as assigned.

Education

Associate degree in nursing

Bachelor of Science in Nursing (BSN)

Registered Nurse license (RN)

Job description

Three Crosses Regional Hospital in Las Cruces, NM seeks a Quality Stroke & Sepsis Coordinator (FT) to lead hospital programs, ensure evidence-based care, and maintain compliance with accreditation and regulatory requirements. The role partners with physicians, nursing, emergency services, and Quality leadership to drive performance improvement, education, and timely reporting.

RN licensed professionals with 3+ years of acute care are encouraged to apply.