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Performance Improvement/Regulatory Coordinator PRN in Orange City, FL at AdventHealth

Date Posted: 2/20/2019

Job Snapshot

  • Job Schedule
    Per Diem
  • Job Category
  • Date Posted:
    2/20/2019
  • Job ID:
    18016877
  • Job Function
    Risk Management
  • Travel
    Yes, 25 % of the Time
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Fish Memorial

Job Description


Description

Performance Improvement/Regulatory Coordinator AdventHealth Fish Memorial

 
Location Address: 1055 Saxon Boulevard Orange City, Florida 32763
 
Top Reasons To Work At AdventHealth Fish Memorial
Career growth and advancement potential
Health Insurance Coverage

Great benefits such as: Educational Reimbursement


Work Hours/Shift:
Per Diem, Days
 
You Will Be Responsible For:
  • Serves as a hospital content expert on performance improvement projects, quality measure consoles and documentation, accreditation and safety. Provides leadership and support regarding questions from staff, leaders and physicians on performance improvement, quality measures, regulatory and accreditation. Utilizes outside resources for complex questions to ensure correct communication and interpretation (i.e. TJC intranet, ECRI, QualityNet websites).
  • Participates in collaboration with or as the designee for the Quality Director, on AHS quality initiatives and/or collaboratives. This may include but is not limited to: Glycemic management, Partnership for Patients/HIIN, AHRQ safety indicators as assigned. Assists with data management, performance improvement, medical record review and meeting organization to help ensure initiative success and goals are met. Utilizes appropriate PowerInsight (PI) reports to coordinate performance improvement and safety projects.
  • Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, performance review councils, and hospital leadership meetings by providing regulatory, quality and safety updates as assigned.  Responsible for ensuring all cases referred to Medical Review are dealt with according to hospital Medical Review policy and medical staff bylaws. This may include screening, reviewing with appropriate department chairman, preparing cases to be brought to committee, completing agenda/minutes for committee meeting, communicating committee decisions to involved medical staff providers and providing updates to Medical Executive Committee and hospital Executive Council. Maintains familiarity with medical staff bylaws as an internal content expert.
  • Responsible for maintaining daily screening process for all inpatient admission throughout hospital. Utilizes appropriate PI reports as verification tool to ensure all patients with coded diagnosis for core measures after discharge have all measures addressed. Responsible for reviewing patient medical records to determine key core measure diagnosis, initiates quality consoles and reviews adherence of documentation to quality measures. When discrepancy or variance is noted, responsible for notifying front line nurse, physician and/or  leadership to ensure correction is made prior to discharge or chart completion deadline. Responsible for completing monthly core measure abstraction by abstracting date elements into corporate approved vendor software. Responsible for utilizing CMS data specification manual and maintaining knowledge on measure definitions to ensure accurate and complete data abstraction. Responsible for performing error checking and validation procedures in conjunction with Premier liaison prior to monthly submission. Responsible for completing all abstraction by AHS monthly and CMS quarterly deadlines.
  • Plans, implements & monitors interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees and teams. Leads special projects for the Chief Medical Officer, Quality Director and Quality Manager while using judgment for the level of discretion and confidentiality needed.
  • Prepares reports and statistical analysis for medical staff and hospital leadership meetings.  Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. 
  • Patient safety and/or risk management designee when quality director and risk manager are out of the hospital or need additional support. Complete and analyze quality event timelines, root cause analysis timelines, review core measure cases, review risk events, notify regulatory bodies of any Code 15 or other reportable events, and identify care variation in case reviews.  

Qualifications
KNOWLEDGE AND SKILLS REQUIRED:
  • Strong computer skills in Microsoft Office Suite (i.e., Word, Excel, Access, PowerPoint, Outlook)
  • Excellent communication skills- written, oral and presentation, to build relationships with all departments, physicians and executive team
  • Must possess presentation skills, as well as negotiation and advocacy skills when interacting with fellow members of the healthcare team as well as outside accrediting agencies, legal bodies, and other healthcare institutions. Internal and external contacts are often problem-driven
  • Analytical ability to interpret data trends
  • Acts independently and demonstrates organizational and problem solving skills
  • Facilitation of various PI methodologies (Six Sigma, Lean, PDSA, etc) PREFFERED.

EDUCATION AND EXPERIENCE REQUIRED:

  • Bachelor’s degree
  • Minimum of 3 years healthcare experience
  • Previous experience in preparing and presenting professional presentations to executive leadership teams
  • Accreditation activities and survey preparation
  • Provider performance improvement activities

EDUCATION AND EXPERIENCE PREFERRED:

  • Bachelor’s degree in a healthcare related field
  • Experience with regulatory, patient safety, Peer Review or OPPE process
  • Healthcare related performance improvement or project management experience
  • Proven ability in areas of leadership/ supervision, knowledge of regulatory aspects of healthcare, QA/QI principles, education and outcomes

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

  • Certified Professional in Healthcare Quality (CPHQ)
  • Six Sigma Performance Improvement Certification
  • Lean Performance Improvement Certification
  • Certified Professional in Healthcare Risk Management (CPHRM)
  • Certified Joint Commission Professional (CJCP)
 
Job Summary:

The Performance Improvement / Regulatory Coordinator provides leadership for safety, accreditation and regulatory activities through relationship with hospital administration and leadership, medical staff leadership, physicians, nurses, and ancillary and allied health departments to improve knowledge and performance for hospital safety, performance improvement and quality initiatives. Assists in the oversight of department staff as directed by the Director and/or Quality Manager. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Provides concurrent case reviews and recommendations to ensure that evidence based best practices are implemented timely.  Responsible for independent coordination of program submissions in compliance with federal guidelines. Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, new hire orientation and hospital leadership meetings by providing accreditation, regulatory, quality and safety updates. Coordinates annual accreditation activities. Serves as the patient safety designee as needed. Responsible for planning, implementation & monitoring of interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees as directed.  Prepares reports and statistical analysis for medical staff and hospital leadership meetings.  Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. Adheres to and enforces the Florida Hospital Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies.  Assures facilitation of the patient grievance process as required by state and federal statutes. Adheres to and enforces the Florida Hospital Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies.



This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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