Summary
The Quality Manager is responsible for the coordination of organizational-wide quality activities in
collaboration with the department Director. Duties includes working with departments to develop
tactics to improve clinical outcomes and compliance with evidence-based practice. Provides the tools,
techniques and skills necessary for outcomes measurement, process improvement as well as strategic
quality planning. Works with leadership, staff and physicians to maximize quality incentive
reimbursement and ensure Core Measure compliance. Supervises the Quality Data Analyst, and the
Quality Data Abstractors.

Essential Duties and Responsibilities
These duties and responsibilities described below represent the general tasks performed on a daily
basis; other tasks may be assigned.

Quality
• Serve as system administrator for QNet and as a resource for Premier Analytic system.
• Monitor and maintain a data collection reliability rating with CDAC > 95%.
• Collaborate with hospital staff and physicians to improve clinical quality.
• Assist with the review medical record documentation to evaluate compliance with designated Core
Measure criteria.
• Assist in reinforcing interpretation of Core Measure criteria to nursing and medical staff as needed.
• Develop and maintain current knowledge of Core Measure requirements, interpretation, and
application.
• Maintain knowledge all CMS quality programs and other pay for performance programs.
• Assist with analysis/drill down of clinical quality improvement and recommends improvement
strategies.
• Assist with performance improvement projects and initiatives as needed.
• Assist with education to medical and clinical staff regarding effective documentation in the medical
record.
• Assist with agenda planning for the hospital Quality Committee and present reports as assigned.
• Chair Sepsis Committee.
• Assist with abstraction of Core Measures to ensure timely completion.
• Establish IRR process and monitor results for all abstracted measures.


Data Management
• Prepare clinical quality reports and communicate compliance with Core Measures and improvement
initiatives throughout the organization.
• In partnership with the Quality Data Analyst manage the Quality and Patient Safety Dashboard,
provide Executive staff and key personnel with the most current information available.
• Create service line quality reports as assigned.
• Work with IT to determine eCQM selection, assist with measure evaluation and submission
determination.
• Establish and maintain data accuracy and data integrity criteria.
• In collaboration with the department Director establish data presentation standards and serve as
resource for department staff regarding data presentation standards.
• Assist Data Analyst with conducting opportunity analysis through data mining and trending.

Management Skills
• Conduct regular meetings with direct reports such as huddles, email updates, and 1-on-1 meetings
to promote ongoing communication and problem solving.
• Contribute to department meetings and other established forums such and Weekly Huddles (virtual)
to enhance intra and interdepartmental communication and to promote staff engagement.
• Assist in the development of direct reports and annual goals for the department.
• Provide direct supervision of the Data Abstractors and Data Analyst.
• Possess strong problem solving and decision-making skills.
• Mentor staff in developing job skills.
• Maintain open lines of communication with all levels of staff.
• Prepare growth and development in existing staff for succession plans.
• Prepare and maintain staff schedules.
• Control the financial performance and FTEs of the department with the specified fiscal parameters.
• Identify and explain monthly variances to the department Director
• Assist with department budget planning.
• Monitor department payroll to assure adherence to policies by staff.
• Ensure staff compliance with policies and procedure and required education and timeframe for
completion.

Professional
• Establish working relationships with customer service characterized by professionalism and
dedication to the goals of Chesapeake Regional Medical Center.
• Effectively manages assigned projects with a level of independence in performance of the role
and/or solution of problems.
• Other duties as assigned to include coverage of essential departmental functions and services.
• Actively participates as the department representative in designated multidisciplinary teams and
committees
• Support clinical operations and clinical initiatives as assigned.
• Attend required hospital-wide orientations, meetings, and in-services.
• Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care.

Supervisory Responsibilities
Reports to: Director, Quality and Patient Safety
Supervises: Quality Data Analyst and Quality Data Abstractors
Responsibilities: Supervises department functions and complete the department’s operating and capital
budgets


Education and Experience
 

Minimum Required Education: Completion of an accredited Registered Nursing program,
Bachelors of Science in Nursing, experience in lieu of degree may be considered.

Preferred Education: Master’s Degree in Nursing

Experience: 5+ years in clinical nursing, 2+ years medical record review, 2+ years in management
Basic knowledge of concepts, practices, and procedures related to quality and process
improvement functions and CMS quality programs.Working knowledge of basic business software such as Excel, PowerPoint, and Word.

Certificates, Licenses, Registrations
Applicants must be licensed to work as a Registered Nurse in the State of Virginia and must obtain CPHQ
or CPPS within one (1) year of hire. BLS required. Green Belt certification preferred. Experience or training
in lieu of certification may be considered.