Informatics Quality Analyst-Registered Nurse

**Must have current RN License***

SUMMARY OF JOB:

Provide nursing informatics support to Clinical Improvement Department and Quality Management Program. Priorities are activities that promote continuous compliance and improvement activities to meet Medicare and Medicaid Conditions of Participation, Joint Commission Accreditation Standards, Healthcare Facilities Accreditation Program/American Osteopathic Accreditation (HFAP/AOA) standards, Bariatric Center of Excellence standards, and others as needed to obtain or maintain hospital accreditation or certifications.

Colorado West HealthCare System participates in Centers for Medicare and Medicaid (CMS), and is deemed in compliance with those Conditions of Participation through its successful accredited status from the Joint Commission and the HFAP/AOA. CWHS is committed to the provision of quality health care to the community it serves, and is accountable to collect and submit data from which the organization is measured. Further, CWHS is committed to a continuous monitoring of the quality of care provided, and collects, analyzes, and presents data to the board and medical staff, providing actionable information from which to assess clinical competence and quality outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Monitors and collaborates to ensure technical and quality compliance with governmental/regulatory rules and regulations.

• Coordinates management action plans for accreditation – ongoing / continual readiness for accreditation surveys (a) The Joint Commission, (b) Healthcare Facilities Accreditation Program, (c) CMS Conditions of Participation, and others as needed to obtain or maintain hospital accreditation or certifications. Essential to this responsibility is the collection, abstraction, analysis and reporting of clinical data.

• Develops systems and procedures to carry out QM/PI functions in alignment with accreditation/regulatory agencies and professional quality organizations, such as the Agency for Healthcare Research and Quality (AHRQ).

• Keeps abreast of new and revised regulatory agency requirements, with additional emphasis on new and evolving electronic quality reporting. Communicates these developments to the team, and collaborates on hospital’s response to these changes.

• Demonstrates familiarity with standards of accreditation and regulatory agencies. Collaborates with team in assessing adherence to these standards.
• Completes and coordinates needed information systems for the data aggregation for Quality Management, such as hospital quality dashboards.
• Timely collection, data abstraction, and maintenance of information from different sources, internal and external improvement initiatives, including ORYX/Joint Commission Core Measures, HEN, PI Data Dashboards, TJC Measures of Success and HFAP Evidence of Success data ( 95% accuracy).

• Provides abstraction, support, and education for data collection for provider reports, such as OPPE/FPPE using internal and external benchmarking systems.

• Ensures the integration of Quality Management improvement activities and ongoing evaluation, including monitoring of appropriate corrective actions (management action plans) and improvements to ensure resolution.

• Drafts responses to quality measure queries from regulatory agencies, such as Hospital Quality Incentive Program (HQIPs) and Hospital Transformation Program (HTP) from Colorado Medicaid.

Collaborates with the multidisciplinary health care team for development and implementation of the Quality Management Program.

• Participates in and provides support to the multidisciplinary departments for the Quality Oversight, Patient Safety, and Process Improvement Committees.

• Participates in the Hospital employee orientation when the need arises; provides Quality orientation to new providers.

• Assesses data-driven quality topics for review across the hospital, including (a) high risk-high volume, (b) low risk-low volume, or problem-prone activities, facilitating the performance improvement framework for all projects. Collaborates with teams to identify outcomes, and plans for improvement following PDSA cycle.

• Participates in department/service Quality organizational committees, task forces, and organizational performance improvement teams as appropriate.

• Recommends selected focus studies to evaluate and improve quality patient care.

• Provides education and consultation to the multidisciplinary Department/Service Lines to accomplish the goals and techniques of Performance Improvement (Rapid Improvement Events/PI Teams).

Supports and Coordinates data collection for the Bariatrics Program Center of Excellence.

• 1. Successfully completes the BSCR Training Program.
• 2. Participates in data compilation for audits and initial and reaccreditation site visits.
• 3. Provides accurate (>95%) and timely data abstraction and data entry of bariatric patient information.
• 4. Periodically attends voluntary in-person professional development seminars offered at various annual meetings (for example, ASMBS, ACS NSQIP, and the ACS Clinical Congress).

QUALIFICATIONS:

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.

EDUCATION:

Bachelor's Degree in Nursing and/or eight (8) years of healthcare organization experience. Proficient in Meditech and Meditech Reports, Microsoft Office. Current working knowledge of Rules/Regulations CMS (CoPs), ORYX Core Measures, and accreditation bodies (TJC & HFAP) preferred. Case Management experience including utilization review and discharge planning preferred.

This position's pay range is: $40.00 - $48.00 per hour, depending on education and experience.

Discretionary bonuses, relocation expenses, merit increases, market adjustments, recognition bonuses and other forms of discretionary compensation may be paid to eligible employees based upon organizational and individual performance.

Benefits:

Employees are eligible to participate in an attractive benefits package including medical, dental, vision, paid time off, education assistance, 403(b) with employer matching, and more. Eligibility is based on employment status. Details regarding specific benefit you may be eligible for will be discussed during the hiring process.

Be Extraordinary. Join Us Today!

Community Hospital recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an equal opportunity employer, Community Hospital is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual’s race, creed, color, religion, gender, national origin or ancestry, age, mental or physical disability, sexual orientation, gender identity, transgender status, genetic information or veteran status. Community Hospital does not discriminate against any “qualified applicant with a disability” as defined under the Americans with Disabilities Act and will make reasonable accommodations, when they do not impose an undue hardship on the organization.

Education

• Bachelors or better

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)