Quality Improvement Coordinator
1 month ago
**SUMMARY**:
Responsible for the coordination of the agency-wide Performance Improvement Program. Ensures that patient care, clinical programs and administrative services are consistent with the current standards of practice and program expectations. Relates effectively with interdepartmental and intradepartmental personnel, medical staff, patients, and outside agencies.
- **To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.**_
**ESSENTIAL DUTIES AND RESPONSIBILITIES**:
- Establishes and maintains Alivio’s Performance Improvement program;
- Conducts quality chart audits as needed on topics such as, but not limited to HEDIS measures, UDS measures, evidence based guideline adherence and PCMH
- Prepares all supporting materials for QIRM meetings, including subcommittee reports, policies and procedures and other items per QI Reporting calendar
- Compiles and summarizes findings from the chart audits with recommendations for quality improvement to the Medical Director, the Quality Steering Committee and the QA committee;
- Coordinates preparation for Joint Commission reviews and for ongoing compliance to clinical Joint Commission standards, with bi-monthly reports to the Medical Director, QA committee, PCMH and NCQA;
- Tracks all completed Incident Reports and patient complaints. These incidents/complaints will be incorporated into the monthly QSC report;
- Coordinates periodic Patient Satisfaction Surveys with clinical support team to enhance change and/or develop clinic services;
- Coordinates periodic Staff Surveys and compile reports for the Medical Director to be used in provider performance assessments;
- Conduct analysis and identify opportunities and action plans for patient satisfaction and staff satisfaction improvement
- Participates in all QIRM and subcommittee meetings to coordinate activities and resources for quality improvement
- Proactively monitors quality metrics and identifies opportunities for improvement
- Facilitates process improvement groups as needed
- Collaborates with all appropriate committees to implement QI changes;
- Supports the Medical Director with QI reports and initiatives to be presented at the monthly provider meetings and at the QA committee of the board;
- Define, monitor and execute on quality initiatives across all departments within the organization
- Work with center (site) staff and teams to improve process and outcomes and promote staff engagement in quality initiatives
- Monitors outcome measures and implementation of newly implemented QI programs and maintains a log of all QI activities;
- (Immunization inventory management? Nursing audits?)
- Coordinates on-going in-service training for all staff regarding standards, policies & procedures;
- Assists EMT in evaluation and implementation of the Risk Management plan;
- Responsible for compliance with external requirements such as HRSA, NCQA, and FTCA;
- Responsible for the claims management process and processing of claims-related activities including, but not limited to, initiating litigation holds, responding to written interrogatories, and communicating with HHS/OGC. Serves as the claims point of contact.
- Performs all other related duties as assigned.
This position requires compliance with all of Alivio’s written standards, including its Standards of Conduct, Joint Commission standards, all policies and procedures and Corporate Compliance requirements. Compliance will be considered as part of the regular performance evaluation.
**SUPERVISORY RESPONSIBILITIES**:
Manages and supervises staff listed below, including hiring, training, evaluating and managing performance to meet departmental efficiency and performance measures in keeping with the Union Collective Bargaining Agreement (CBA), Personnel Policies and Procedures and prevailing employment laws as appropriate
- Not applicable
**KEY INTERRELATIONSHIPS**:
- Executive Management Team
- RN Clinical Coordinator
- Safety Officer
- Quality Steering, Peer Review and sub-committee chairs
**WORKING CONDITIONS**:
OSHA Category 2 - Involves no regular exposure to blood, body fluids, or tissues, but may require unplanned tasks that involve exposure to blood, body fluids, or tissues.
**QUALIFICATIONS**:
**Education**:
RN, Bachelors degree required
**Licensure**:
Registered Professional Nurse in the State of IL
**Experience**:
A minimum of 2 years of experience with Joint Commission, PCMH, and Meaningful Use standards for ambulatory care or hospital settings, as well as quality and risk management.
**Special Training**:
Quality management JCAHO certificate
**Demonstrated Competencies**:
Requires strong management ability to implement and maintain organization-wide systems. Must be Bilingual
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