Primary responsibility is to assist in the improvement of clinical effectiveness and continual readiness for Joint Commission surveys. Oversees performance improvement activities, regulatory compliance, and other initiatives that lead to effective clinical resource utilization and improvements in quality. Promotes interdisciplinary collaboration and teamwork to promote excellence in patient centered care. Promotes patient education of common disease states and management.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor of Science in Nursing (BSN) AND Three (3) years of clinical experience in a healthcare setting with responsibilities reflecting direct management of patient care including planning, coordination, and delivery of services
OR Associate's Degree in Nursing (ASN) AND Five (5) years of clinical experience in a healthcare setting with responsibilities reflecting direct management of patient care including planning, coordination, and delivery of services.
2. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Advanced degree (MSN, MPH, MPA)

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists in the development and implementation of quality activities and monitors quality indicators for assessment of quality across the continuum of care (ambulatory and inpatient).
2. Develops and implements mechanisms for ongoing data collection, analysis, and reporting of quality indicators. Initiates mechanisms to ensure timely and accurate reporting of data.
3. Monitors appropriate criteria and reports the data for specific procedures and services.
4. Develops performance improvement initiatives throughout the institution and supports the impetus for sustained performance improvement.
5. Works collaboratively with the Decision Support personnel and staff for variance tracking.
6. Works in collaboration with the interdisciplinary health care team to support resource utilization and quality improvement. Utilizes information systems to collect and analyze data.
7. Collects, analyzes, and presents data via internal software systems, external comparative databases and through manual review. Collects data through survey audits of departments, chart review, and staff interviews.
8. Prepares the institution (ambulatory and inpatient) to successfully meet Joint Commission standards and Centers for Medicare and Medicaid Service (CMS) conditions of participation.
9. Analyzes data for trends and for medical staff and institutional compliance with Joint Commission standards and CMS conditions of participation.
10. Develops and submits reports for appropriate individuals and committees within the organization. Interacts with faculty and staff to present quality initiative updates, reports, and education.
11. Assists in the development of appropriate policies, processes, and activities to support continuous readiness for Joint Commission and Centers for Medicare and Medicaid Services. Ensures timely and accurate monitoring of patients' care of compliance with Joint Commission Core Measures and Centers for Medicare and Medicaid Services Scope of Work initiatives.
12. Assists in the implementation of evidence-based indicators associated with Joint Commission Core Measures and Centers for Medicare Services Scope of Work initiatives and monitors these indicators for compliance.
13. Develops and implements mechanisms for ongoing monitoring and analysis of evidence-based indicators.
14. Monitors appropriateness criteria and alerts services of patient-centered opportunities.
15. Documents evidence of compliance or exclusion criteria for the evidence-based indicators in the medical record. Develops performance improvement initiatives throughout the institution related to evidence-based indicators and supports the impetus for sustained performance improvement.
16. Analyzes data for trends and for medical staff and institutional compliance with Joint Commission Core Measures and Centers for Medicare and Medicaid Services Scope of Work initiatives.
17. Interacts with faculty and staff to attain high levels of compliance with Joint Commission Core measures and CMS Scope of Work initiatives.
18. Assists in the development of appropriate policies, processes, and activities to support compliance with Joint Commission Core Measures and Centers for Medicare and Medicaid Services Scope of Work initiatives.
19. In conjunction with Insurance Services, participates in payor-based quality improvement initiatives (QualityBLUE, Ambulatory QualityBLUE). Presents findings, initiatives, and recommendations to payors.
20. In conjunction with CMS, QualityBLUE, Get-with-the-Guidelines and other best practices and initiatives, provide and participate in patient education and disease management.
21. Interact and educate patients on disease states, medical management and possible adverse events (Congestive Heart Failure, Anticoagulation, etc.)
22. Collaborates with physicians, nursing staff, and other health care providers to ensure comprehensive, coordinated patient and family education. Promotes excellence in practice related to disease state management education by role-modeling advances skills and providing instruction and expertise in dealing with complex problems.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Frequent walking, standing, stooping, kneeling, reaching, pushing, pulling, lifting, grasping are necessary body movements utilized in performing duties through the work shift.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office and hospital setting

SKILLS AND ABILITIES:

1. Demonstrates computer literacy.
2. Demonstrates assertiveness and effective interpersonal communication.
3. Utilizes community and system resources.
4. Must be flexible.
5. Excellent written and verbal communication skills.
6. Must be able to negotiate.
7. Must be competent in analysis and research methods.

Additional Job Description:

Scheduled Weekly Hours:
40

Shift:

Exempt/Non-Exempt:
United States of America (Exempt)

Company:
WVUH West Virginia University Hospitals

Cost Center:
405 UHAE Quality Management

Address:
2500 Hospital Drive

Martinsburg

West Virginia