Position Summary: Supports the organization’s quality, regulatory, and performance improvement activities.  This position is responsible for coordinating quality and regulatory data collection, validation, reporting, and follow-up; supporting compliance with CMS, Joint Commission, and other regulatory requirements; and collaborating with clinical and operational leaders to identify opportunities for improvement and sustain compliance. 

Essential Duties and Responsibilities:

Quality Improvement

• Collaborates in the development, implementation, and evaluation of clinical services and quality initiatives.
• Supports key strategies to drive quality improvement to meet strategic and clinical excellence objectives
• Gathers, analyzes and reports data related to performance and achievement of project objectives and timelines. Tracks issues and works to improve processes, efficiency and compliance of best practice standards including electronic documentation standards.
• Supports organization-wide quality improvement initiatives, including data collection, measurement, monitoring, and reporting. 
• Assists departments and leaders with identifying performance gaps and developing improvement strategies to facilitate the standardization of best practices that promote high reliability
• Monitors quality metrics and trends and escalates significant variances or areas of concern to appropriate leadership

Data collection:

• Responsible for accurate and timely quality data abstraction and validation through detailed chart reviews required for submission for regulatory, accreditation, CMS and benchmarking reporting
• Collects, analyzes and validates quality and performance improvement data.
• Monitors quality metrics and trends and escalates significant variances or areas of concern to appropriate leadership
• Generate performance improvement reports from quality databases, including monthly reports for distribution/analysis of findings as well as ad hoc reports
• Summarize, analyze, and present key data findings to organizational leaders and key stake holders to drive improvement in quality priorities.
• Supports preparation of quality reports, dashboards, scorecards, and presentation for leadership and committees. 

Other

• Serves on specialty and/or unit committees, councils, and teams, as well as professional organizations.
• Maintain current knowledge of industry standards by proactively assessing changes in healthcare regulation, accreditation standards and operational best practices through available resources and professional development opportunities to serve as educational resource to the organization
• Monitors workflow to ensure strict deadlines for submission are met
• Handles sensitive, confidential information responsibly
• Exhibits effective verbal and written communication skills
• Performs other job-related duties as assigned

Requirements:

• Registered Nurse, BSN required, MSN preferred or ancillary clinician with equivalent degree in area of expertise
• Minimum 2 years clinical quality experience
• Experience with Cerner EMR preferred
• CPHQ Certification preferred

Work Shift Details:

Department:

At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members.   

Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes:

·       Medical, Dental and Vision plans

·       Life Insurance

·       Flexible Spending Account

·       Other voluntary benefit plans

·       PTO and Sick time

·       401(k) plan with a match

·       Wellness program

·       Tuition Reimbursement

Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match.  However,registry employees are ineligible for Health and Welfare benefits.

The expected pay for this position is listed below:

The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more.