Quality/Accreditation Coordinator for Clinic & Out-Patient Settings

Position Summary: Responsible for interpretation, implementation and monitoring of the various quality initiatives in the Clinic & Out-Patient settings that includes but not limited to Merit-Based Incentive Payment System (MIPS), Blue Cross Blue Shield (BCBS), Commercial Payors, Press Ganey and the Center for Medicare/Medicaid Services (CMS) OP Quality Reporting program.  Works in coordination with leadership and associates to ensure quality metrics are incorporated into workflows and that the benchmarks are being met.  Responsible for interpretation and compliance of a variety of regulations as it relates to Medicare Conditions of Participation and Det Norske Veritas (DNV) Accreditation.  

Qualifications: 

Required:

Bachelor's or Master's Degree in Nursing. Exemplifies the core values of Excellence, Professionalism, Trustworthiness, Respect, Compassion and Spirituality. Strong organizational skills and attention to detail. Proven ability to coach and train to varying learning styles. Must be able to link the clinical effectiveness and clinical informatics arena’s. Strong skills in use of Microsoft Office Prefer 3-5 years clinic experience.

Responsibilities:

Initiates, monitors, and maintains data collection for identified quality metrics. Responsible for proving project management and facilitation, as well as clinical oversight and support for development, coordination, implementation and evaluation of quality improvement activities such as performance improvement and patient safety initiatives. Works closely with Clinic and Out-Patient leadership, medical staff and quality teams to identify opportunities for performance improvement and detect non-conformance issues. Responsible for providing education and assisting leadership in developing Performance Improvement activities utilizing the storyboard format and Plan-So-Study-Act (PDCA) process.  Responsible for developing and maintaining clinic and out-patient scorecards. Chairs the clinic quality committee and is responsible for agenda items, action plans and follow-up. Participates in long range planning for all of the Clinic and Out-Patient quality programs. Stay current on payor quality programs and requirements. Stays current on best practices using evidence-based standards.  Collaborates with clinic and out-patient staff to ensure that compliance with regulatory requirements is in a constant state of readiness. Responsible for ISO audit process and reporting of findings to the individual department and to the Quality Committee.  Ensure compliance with completing action plans for non-conformities.  Provides education related to accreditation and certification processes to all levels of associates, providers and leadership. Monitor and assess compliance with healthcare regulations and standards. Participates in conducting environmental surveillance rounds which includes observation of clinical and non-clinical departments evaluating patient safety, infection control and environmental safety. Completes findings in V-survey and monitors compliance with non-conformities.  Assists in the development and implementation of the International Standardization of Organizations (ISO) process and National Integrated Accreditation of Healthcare Organization (NIAHO) process. Assists in developing policies, procedures, and protocols to maintain standards of care and regulatory requirements. Maintains familiarity with all relevant emergency management policies and procedures; participates in drills and post-event debriefings and provides constructive input to improve the processes. Provides positive leadership by an environment of teamwork, open communication and customer service.  Provides a supporting role for accreditation and quality for Pawnee Valley Hospital.

Patient Interaction: Periodic 

Infection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to, blood borne pathogens, bodily fluids and bio-hazardous materials as it applies to your daily work environment.

HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Hays Medical Center based on the following criteria:
Primary – required (routine) to do the job;
Secondary – required for the job, but mostly be exception; and
None – no approved access

Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion

Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical
None:
Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes

Secondary:
Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates