Monitors and maintains compliance with governmental/regulatory rules and regulations related to performance improvement (PI); ensures all hospital inpatient quality reporting (IQR) and hospital outpatient quality reporting (OQR) requirements are met for the Centers for Medical and Medicaid Services (CMS), the Joint Commission (TJC), and other payer or regulatory body requirements; ensures coordination of Quality Management staff for abstraction of Core Measure data elements according to specification guidelines; ensures the accuracy and completeness of the validation process for IQR, OQR, and electronic clinical quality measures (eCQM); works with Quality Management staff to perform quarterly quality checks prior to data submission; collaborates with other departments and Quality Management staff to gather and enter yearly required quality indicator components; remains current on hospital quality reporting requirements and PI facilitation methods; recommends inpatient/outpatient measure process and documentation improvements to support optimal patient outcomes; acts as liaison between the quality department and HSIS to ensure that department's data needs are met, as well as making recommendations for EHR Workflow changes to promote best practices by clinical staff; acts as a resource and educates hospital personnel about patient quality; participates and/or coordinates various committees of the hospital including, but not limited to the PI Council and the Patient Safety Committee; participates in and/or coordinates Root Cause Analysis teams when needed; participates in and/or coordinates Failure Mode and Effect Analysis teams when appropriate; collaborates with the multidisciplinary health care team regarding development and implementation of the QM program; recommends topics for review, including, but not limited to high risk, high volume, or problem-prone activities, facilitating the performance improvement framework for all projects; provides education to the multidisciplinary Department/Service to accomplish the goals and techniques of Quality Assurance/Performance Improvement; assists in the preparation process for accreditation and regulatory surveys, as needed; assess hospital compliance with accreditation standards and regulatory agencies related to acute patient care and performance improvement and assists leader with understanding and adherence to these standards; participates in patient tracers and mock accreditation surveys to evaluate and make recommendations to ensure compliance with patient care and performance improvement standards; monitors and evaluates results of surveys as it relates to Performance Improvement opportunities and other care monitoring results; submits the annual medical care evaluation (MCE) study to the state Quality Improvement Organization (QIO); ensures the National Patient Safety Goal monitoring is completed monthly and reports in committees quarterly; assists in performing personnel functions for the department to include recruitment, hiring, orientation, supervising, evaluations, counseling, disciplinary actions and education, applying University and Health System policy related to personnel functions; assists in preparing and monitoring the annual budget; prepares reports, attends, and presents committee meeting materials; assists in developing, implementing, and updating hospital and department policies and procedures in a collaborative and interdepartmental process according to the Joint Commission and CMS standards; assists in updating the Quality Improvement Plan according to accreditation agency requirements; prepares the Quality Department annual reports, contact evaluation report, and Quality and Safety dashboard report; assists with the American Heart Association and Certification performance improvement data submission; participates in the Hospital staff and Medical staff orientation and annual updates; responsible for coordinating and leading multidisciplinary teams to improve documentation, patient safety, and quality of care; and assumes day-to-day responsibilities of the Quality Manager, in his/her absence.Bachelor's degree in a healthcare related field from an accredited institution as approved and accepted by the University of South Alabama, two years of professional quality management or directly related experience in a healthcare setting, and current licensure with the state of Alabama in clinical field of study.
A master's degree is preferred. Supervisory experience is preferred. CPHQ certification is preferred. Proficiency in Microsoft Word and Excel is preferred.