Job Details:

Provides overall clinical and quality support to the Department of Quality/Performance Improvement, including workflow, quality review entries, analysis and report generation.

Responsibilities:

• Gathers and submits quality management information data to regulatory agencies as needed (i.e., Q-Net, Midas, IPRO).

• Performs chart reviews to ensure compliance with standards of care for initiatives (CMS, DOH, DNV).

• Assists the Medical Staff Peer Review process when needed. Conducts chart reviews and investigations. Prepares documentation for peer review meetings and manages physician notification. Attends Medical Staff Peer Review Committee Meetings as requested. Assists in maintaining a peer review database. Provides reports to Director of Risk & Patient Safety.

• Assists with conducting mortality reviews

• When appropriate or necessary, attends committees where monitoring and other quality review or Performance Improvement activities are performed.

• When appropriate or necessary, attends committees where monitoring and other quality review activities are performed as agreed upon by the Committee Chair, Chief Medical Officer and Director of Quality and Education.

• Attends and participates in committee meetings as needed or assigned by the Director of Risk & Patient Safety.

• Reviews incident reports for quality issues as needed. Communicates findings to Risk Manager, Chief Medical Officer and/or other departments as appropriate for Margaretville Hospital.

• Assists with the identification and management of NYPORTS including chart reviews, investigation, and preparation of reports for electronic transmission as needed.

• Assist with IPRO Quality Process including chart reviews, physician responses to IPRO.

• Identifies and reports liability issues to the Risk Director – assists with responses, data collection, & coordination of staff meetings as needed for Margaretville Hospital.

• Acts as liaison to other departments when necessary with quality review issues for Margaretville Hospital.

• Establishes and maintains collaborative relations with physicians, nurses and other hospital staff to ensure successful interdisciplinary care and communication for Margaretville Hospital.

• Assists with performance improvement processes/projects as needed.

• Coordinates compliance and correspondence of referrals to staff related to quality case reviews for Margaretville Hospital.

• Participate in, prepare for, and assist in coordination for regulatory surveys.

• Assists Risk Manager with any Risk Management related tasks as needed.

• Performs any other duties as assigned.

Education:

• R.N. required; A.A.S minimum, B.S.N. or M.S.N. Graduate of Accredited School of Nursing preferred

Experience:

• 2 yrs. Clinical experience; prior experience in Quality/Critical Care preferred

Training/License:

• R.N. with current NYS License

Other:

• Prior experience in Nursing, medical record review and knowledge of regulatory agency requirements

About Us:

HealthAlliance Hospital