Quality Nurse Coordinator

About the Role

Facilitates, in collaboration with the Manager of Quality Management, accurate, timely and consistent clinical data to public reporting databases and agencies, including The Joint Commission (Oryx) and CMS. Reviews paper and electronic medical records, interprets and analyzes documentation, and extrapolates pertinent health information needed for determining clinical quality and core measures required by The Joint Commission, CMS, and other clinical reporting programs. Accurately enters the data directly into the electronic data collection database. Researches all available resources on missing, conflicting, or ambiguous information in the medical record. Applies skilled judgment in determining that deviations from guidelines may indicate an omission or inaccuracy within the patient’s medical record. The position requires full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center, demonstration of Core Values, and support of the hospital’s strategic plan and Performance Improvement Plan (PIP).

Knowledge

• Current knowledge of regulatory/accreditation standards, hospital policies and procedures, and medical staff bylaws.
• Assists with design of presentations meaningful to the intended audience.
• Provides feedback and collaborates with staff to eliminate risks and improve performance and safety.
• Demonstrates ability to teach effectively at all organizational levels.
• Skilled in medical record review specific to abstraction criteria.
• Ability to apply Quality Improvement methodology.
• Thorough understanding of medical terminology.
• Demonstrated computer skills.
• Thorough understanding of formulary drugs and pharmacological indications.

Responsibilities

• Perform review, investigation, and analysis of occurrences and cases identified through occurrence reporting, generic screens, etc., meeting criteria for peer review.
• Coordinate internal departments and external entities to ensure compliance with company policies and State/Federal regulatory and accreditation standards.
• Formulate professional data reports and presentations for hospital committees and physician specialty groups.
• Understand abstraction components, including inclusion and exclusion criteria specific to measurements, and adhere to established guidelines for criteria abstractions.
• Complete patient data entry accurately and within established timeframes.
• Analyze data at aggregate and patient levels to identify trends and quality improvement opportunities.
• Support departmental goals related to Truven Top 100 hospital recognition, Leapfrog, CMS star rating, and HAC program compliance.
• Maintain regular updates of policies and procedures.
• Perform medical record reviews associated with quality improvement; analyze data collected for QI projects; track, trend, and prepare information for appropriate committees.
• Participate in daily department operations, including PI database management and case review involving patient safety and core measures.
• Generate ongoing physician‑specific quality reports, including tracking and trending of peer reviews for OPPE and PPE purposes.
• Perform other duties as assigned by the immediate supervisor or administration.

Education, Training & Experience

• Either (1) Registered Nurse license in California with a bachelor’s degree in Nursing; or (2) Bachelor’s degree in a healthcare‑related field; or (3) Master’s degree or higher education.
• Strong clinical background and broad knowledge base preferred.
• Excellent verbal and written communication and computer skills.
• Strong analytical and problem‑solving skills.
• Knowledge of quality improvement processes and techniques.
• Two (2) to three (3) years of experience in Performance Improvement or Risk Management.

Licenses & Certifications

• Current California RN license.