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Coordinates quality improvement/quality assurance/patient safety activities to maintain and improve patient care services. Performs appropriate concurrent and retrospective quality review studies using methodologies that include, but are not limited to electronic and hard copy medical record review, data extraction and aggregation, computer data entry using internet-based software and simple calculations. Follows-up and investigates patient complaints and participates in other QRM activities as assigned. Assists with Joint Commission activities and policy revision developments as assigned.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Five (5) years acute care clinical experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor of Science in Nursing (BSN).

EXPERIENCE:

1. Data Analysis with a background in one or more of Quality/Patient Safety/Risk Management/Joint Commission.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Coordinates quality improvement/quality assurance/patient safety activities to maintain and improve patient care services.

2. Performs appropriate concurrent and retrospective quality review studies using methodologies that include, but are not limited to electronic and hard copy medical record review, data extraction and aggregation, computer data entry using internet-based software and simple calculations.

3. Analyzes, interprets and reports data to the appropriate departments and hospital committees.

4. Responsible for leading and directing quality reviews, ORYX/Core Measures/Performance Measures and other performance initiatives and maintains competency with Premier Quality software for that purpose.

5. Interacts with physicians and staff to improve documentation for data extraction for required Core Measures and other performance/quality measures.

6. Creates reports for Performance Improvement Committee (and other committees as assigned) based on each quarters' data.

7. Investigates and follows through on patient/family complaints received in QRM and assures feedback to patient family in a timely manner as necessary.

8. Assists with PI at CHI by facilitating Root cause analysis.

9. Assists with Joint Commission activities as necessary.

10. Assists with policy revision/development as necessary.

11. Consistently documents to ensure that supplies and medications are accurately charged.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Must meet Department of Labor’s MEDIUM duty standard (MEDIUM WORK- exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 10 pounds of force constantly).

2. Able to bend, stoop, reach and be capable of normal rotation, standing and walking for an 8-10 hour shift.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. May be scheduled to work various shifts based on departmental and patient needs.

2 May be required to travel between facilities/buildings.

SKILLS AND ABILITIES:

1. Use a computer keyboard, monitor and mouse.

2. Answer telephones and transcribe messages.

3.

Communicate verbally, written and electronically with healthcare personnel, families and patients.

Additional Job Description:

Medical Staff OPPE, medical staff support

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

BMC Berkeley Medical Center

Cost Center:

405 UH Quality Management

Address:

2500 Hospital Drive

Martinsburg

West Virginia

Equal Opportunity Employer

 

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.