Overview

• Facilitates, in collaboration with the Manager of Quality Management accurate, timely and consistent clinical data to public reporting databases and agencies, including The Joint Commission (Oryx), and CMS. Reviewing paper and electronic medical records, interpreting, analyzing medical record documentation, and extrapolating pertinent health information needed for determining clinical quality and core measures required by The Joint Commission, CMS and other clinical reporting programs. Accurately entering the data directly into our electronic data collection database. Researching all available resources on missing, conflicting or ambiguous information in the medical record.  Applying skilled judgment in determining that deviations from these guidelines may indicate an omission or inaccuracy within the patient’s medical record.
• This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the Performance Improvement Plan (PIP).

Responsibilities

KNOWLEDGE OF WORK:

 

• Demonstrates current knowledge of regulatory/accreditation standards, hospital policies and procedures and medical staff by laws.
• Assists with design of presentations which are meaningful to intended audience.
• Provides feedback and collaborates with staff in the effort to eliminate risks and improve performance and safety.
• Demonstrates ability to teach effectively to all levels of the organization.
• Demonstrates skills in Medical Record review specific to abstraction criteria.
• Demonstrates the ability to apply Quality Improvement methodology.
• Thorough understanding of medical terminology.
• Demonstrated computer skills.
• Thorough understanding of formulary drugs and pharmacological indications.

 

SPECIFIC JOB DUTIES:

 

• Performs review, investigation and analysis of occurrences and cases identified through occurrence and cases identified through occurrence reporting, generic screens, etc, meeting criteria for peer review.
• Coordination of internal departments and external entities to ensure compliance with company policies, and State/Federal Regulatory and Accreditation standards.
• Ability to formulate professional data reports and presentations for hospital committees and physician specialty groups.

• Understands abstraction components, both inclusion and exclusion criteria, specific to measurements.

• Adheres to established guidelines for criteria abstractions.

• Completes patient data entry accurately and within established timeframes.

• Analyzes data, both on aggregate and patient level as needed, to identify trends as well quality improvement.
• Understands the Department goals of strong results in the following programs/initiatives: Truven Top 100 hospital recognition, Leap Frog, CMS star rating, no penalties with HAC program.  
• Maintains regular updates of policies and procedures.
• Performs medical record reviews associated with QI; analyzes data collected for QI projects; tracks, trends and prepares information to submit to appropriate committees
• Involvement in the daily operations of the department to include:  PI database management; case review involving Patient Safety and Core Measures.
• Generate ongoing physician specific quality reports including tracking and trending of peer reviews and for OPPE, PPE purposes.
• Performs other duties as assigned or required by the immediate supervisor or Administration.

  Qualifications

EDUCATION/TRAINING/EXPERIENCE:

 

Requires either: (1) Registered Nurse license in the state of California with a bachelor’s degree in Nursing; or (2) Bachelor’s degree in a Healthcare-related field; (3) Master’s Degree or higher education

Strong clinical background and broad knowledge base preferred

Excellent verbal and written communication and computer skills

Strong analytical and problem solving skills

Knowledge of quality improvement processes and techniques

Two (2) to three (3) years’ experience in Performance Improvement or Risk Management, Preferred

LICENSES/CERTIFICATIONS:

 

             Current California RN License