Coordinator-Quality and Accreditation

About the Role

Participates in the planning, development, and implementation of goals and objectives related to accreditation, certification, regulatory, federal, and state requirements. Coordinates gathering and distributing of data in support of these clinical and regulatory programs. Conducts portions of the medical staff performance improvement process, including profiling with intent to maintain and improve quality of care and service. Provides consultation to physicians, staff, performance improvement teams, and departments regarding improvement methodologies and processes. Reports to Director of Quality.

Responsibilities

• Coordinates, implements, and evaluates hospital and medical staff performance improvement activities.
• Coordinates, implements, and evaluates clinical quality initiatives for external comparative benchmarking.
• Coordinates and facilitates the accreditation and regulatory compliance processes.
• Communicates effectively with physicians, staff, and external entities.
• Educates hospital staff and physicians regarding Performance Improvement tools and techniques.
• Contributes to preparation for accreditation, certification, and surveys.
• Completes chart abstraction and data analysis.
• Assists with development, implementation, and evaluation of quality plan and performance improvement initiatives.
• Directs community education and prevention programs.
• Identifies trends for strategic planning and performance improvement.
• Completes assigned goals.
• Performs other duties as assigned.

Requirements

• Minimum of 5 years of experience in a clinical setting.
• Previous experience in quality and performance improvement preferred.
• Registered Nurse licensure required.