Direct the activities of the Quality Improvement, Social Service, Case Management/Appeals , Infection Control and Medical Staff Services, Health Science Library/CME program, Gainsharing Departments in collaboration with the Director/Manager/Coordinator of each department or of each department function as assigned. Plan and oversee all Quality Improvement department functions including, r Regulatory standards compliance, Medical Staff Peer Review process, quality and peer review data for both Physician and Allied Health Professional’s profiles for reappointment and for OPPE and FPPE regulatory requirements. Monitor the performance of all quality councils, prepare the reports for review by the Continuous Quality Review Council (CQRC), evaluate the year end performance of all councils and prepare and present the annual Quality Improvement Plan for approval. Responsible for multiple databases related to the tracking of quality and safety initiatives and reporting of such initiatives to the leadership team. Coordinate regulatory agency surveys and timely submission of action plans to include annual application and changes as required. Serve in role of Site Administrator for the hospital for Joint Commission, Core measure reporting through approved vendor, Quality Net Database, NDNQI for nursing sensitive measures and RN Satisfaction Survey, and Crimson for physician profiles. Review Length of Stay, readmissions and denials and complex cases in collaboration with Case Management, Social Service and Physician Advisor. Coordinate Infection control projects for external reporting by providing assistance of the QI Department to the Infection Control Manager. Act as a Liaison for issues involving Medical Staff; provide assistance to the Medical Staff Officers and Medical Staff Department/Division Chairman and provide support to the CME Coordinator and CME Medical Director to maintain CME Program Accreditation. Serve as the Hospital Liaison for the RWJUHR New Brunswick Physician Coordinating Council and other councils as assigned.
RN with a minimum of 5 years experience in the clinical area required, Master’s degree preferred. Minimum of 3 years management experience in the Quality Improvement area with knowledge of Regulatory Standards (NJDHSS, CMS, TJC, Patient Safety Act Reporting and Sentinel Event/Joint Commission Reporting). Knowledge of/or training in various Performance Improvement databases for internal and external reporting (Quadramed, Leapfrog, IHI, AHRQ, Healthgrades, Joint Commission site, Hospital Compare [NJDHSS and CMS], Quality Net, NDNQI, Press Ganey) is preferred. Computer experience in Microsoft Office Suite is required. Knowledge of Medical Staff Privileging and Credentialing Process and database.