Job DescriptionJOB SUMMARYThe Quality Manager is responsible for overseeing regulatory readiness, quality measurement, public reporting and pay-for-performance programs and initiatives. . Serves as a consultative resource in clinical design of systems for end users with the purpose of driving quality outcomes. As the hospital expert in regulatory and reporting programs this position will serve as a resource to staff and key stakeholders in ensuring compliance to the latest quality mandates from regulatory bodies. As a key leader in the Quality department, this position will be responsible for interpreting applicable regulatory specifications, identifying organizational regulatory requirement gaps, overseeing the collaboration with key stakeholders to guide improvements activities for compliance. The position is responsible for continuous collaborative learning, mentoring direct reports and other staff of the department, maintaining competency and identifying and supporting performance improvement projects and activities throughout the organization through education, planning and project oversight.
ESSENTIAL JOB RESPONSIBILITIES- Directs team to ensure CMS quality programs, Inpatient Quality Reporting (IQR), Outpatient Quality Reporting (OQR), are followed including abstracting and reporting measures (human, electronic, claims) with the most up-to-date regulations.
- Directs team that participates in the implementation, validation of MIPS quality measures for Eligible Hospital and Eligible Providers; and MIPS value pathways.
- This position stays up-to-date on the pay-for-performance programs that include but are not limited to: Hospital Value-Based Purchasing (VBP) Program, Hospital Acquired Conditions (HAC) Penalty Program, and Hospital Readmission Reduction Program (HRRP), Merit-based Incentive Payment System (MIPS) with real time review and reporting to key stakeholders in the organization. Reviews and analyzes data and reports from CMS to ensure accuracy, identifying opportunities, and reporting to key stakeholders.
- Leads or participates in organization strategic teams, such as, sepsis, glycemic control, mortality, readmissions, patient safety indicators.
- Establishes mechanisms for proactive identification and correction of regulatory issues.
- Collaborates with Information Technology and Data Analytics to ensure accuracy of data in the department both for internal use and public reporting as applicable.
- Acts as a content expert and provides direction with regulatory compliance (such as CMS and The Joint Commission).
- Responsible for understanding and reporting additional programs as requested by the organization such as Blue Cross Blue Shield Kansas Hospital Quality Reporting Program.
- Applies performance improvement methodologies and tools to projects (such as, but not limited to Lean, Six Sigma, statistical process control, DMAIC, FMEA, RCA, process mapping, cause and effect diagrams).
- Understands LMH Health's strategic plan and aligns improvement efforts with the strategic goals of the organization.
- Promotes a culture of quality, safety, high-reliability, patient and staff engagement, and performance excellence.
- Directly supervises Quality specialists and accreditation coordinator.
- Performs other duties as needed or assigned.
JOB QUALIFICATIONSRequired:
- Master's degree or equivalent experience in nursing, public health, health administration, or health related field required
- Current applicable licensure (ex. RN, etc.)
- Five years of relevant acute-care hospital experience in quality, patient safety, regulatory and accreditation or an equivalent combination of education and experience which would demonstrate the required knowledge, skills and abilities may be qualifying;
- Certification with CPHQ and/or CPPS; or willingness to obtain the certification within 24 months of hire.
- Demonstrated experience in supervisory/leadership.
- Yellow Belt in Lean Six Sigma or willingness to obtain within 12 months of hire date.
- Demonstrated professional communication: verbal and written. Clear and effective communication to diverse audiences. Possesses expert leadership skills and maturity in managing difficult situations and conducting crucial conversations.
Preferred:
- Advanced knowledge of data analysis and utilization (including Microsoft Excel, Word and Power Point).
- Green Belt in Lean Six Sigma
- Basic knowledge of statistics and statistical methods of analysis.
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