Job Abstract

Position Summary

Performs quality improvement activities in identified areas in need of improvement. Performs medical staff peer review activities with assigned medical staff departments and committees including Focused Professional Practice Evaluations (FPPE) and Ongoing Professional Practice Evaluations (OPPE). Involved with hospital wide performance improvement projects and studies.Responsible for the collection and distribution of assigned National Quality Measures, (CMS, TJC, NJDOHS, QIO)

Primary Position Responsibilities

1. Accurately collects, analyzes and distributes data regarding assigned National Quality Measures (Core Measures) within assigned time frames. Works with appropriate staff to implement quality improvement projects to increase compliance

2. Performs Medical Staff Peer Review activities for assigned medical staff departments. Creates reports regarding the same. Configures and distributes medical staff FPPE and OPPE reports on a scheduled basis.

3. Assists the Patient Advocate with complaints, grievances and service recovery.

4. Involvement in quality improvement initiatives when assigned.

5. Assists with Regulatory compliance with Joint Commission, NJ DOH standards.

Qualifications

Minimum Education:

Required:

Bachelor’s degree in Nursing, Healthcare Administration or related field.

Preferred:

Master’s Degree in Nursing, Healthcare or Health Related Science

Minimum Years of Experience (Amount, Type and Variation):

Required:

5 years clinical experience

Preferred:

2 years experience in Healthcare Quality

License, Registry or Certification:

Required:

None

Preferred:

CPHQ certification

Certificate and/or Advanced Specialized or Technical Training in Nursing &/or Certified Professional in Healthcare Quality, (CPHQ)

If an RN, Current NJ RN license

Knowledge, Skills and/or Abilities:

Required:

Excellent analytical, communication, interpersonal, and organizational skills.

Knowledge and experience in Performance Improvement techniques.

Experience in working with PI teams as a member and leader.

Experience with MS Office software.

Experience in data analytics and data display

Preferred:

Advanced MS Office and database skills