Job Abstract

• Works with and motivates staff, physicians and leadership to participate in performance improvement activities
• Manages performance improvement projects throughout the medical center
• Analyzes data to track and trend performance outcomes
• Coordinates accreditation and regulatory surveys
• Stays current with regulatory standards updates
• Coordinates core measures program with Quality Manager and assists with core measures data abstraction and submission to TJC and CMS
• Conducts tracer activates/quality rounds to ensure ongoing survey readiness
• Collaborates with all disciplines/departments in the organization to obtain the highest level of patient outcomes
• Facilities quality meetings and PI team meetings
• Educates all members of the organization, including physicians and senior leaders on performance improvement tools and processes
• Coordinates policy process within the organization to ensure policies are updated appropriately and new policies are written as needed

Requirements:

BS in healthcare related field with clinical experience preferred.

Master’s degree preferred

CPHQ preferred or to be obtained within 2 years of service is required

3-5 years of proven experience in healthcare quality

Knowledge of regulatory and accrediting agency (NJ DOH, TJC, CMS, OSHA) standards is a plus

Medical chart review skills preferred

Strong computer skills required; Microsoft office and statistical software (willing to train)

Interpersonal requirements:

Strong verbal, written communication and presentation skills, must be an organized self-starter, as

well as a team player

Talent for leading and facilitating group and team meetings

Ability to maintain a calm, professional demeanor under pressure

Comfort in handling challenging situations that may involve adverse outcomes