Coordinator Quality Reporting Programs-ARMC(Days)FT

Adena Health•Chillicothe, OH

6d•Onsite

About The Position

The Quality Reporting Programs Coordinator works in a High Reliability Organization and reports to and assists the Director of Infection Prevention and Quality Reporting Programs. The coordinator helps maintain compliance with regulatory reporting requirements for applicable programs, including CMS and TJC, and oversees clinical quality data abstraction for public and other reporting requirements across all Adena hospital locations. The role supports quality activities aligned with service-line, certification, regulatory, and organizational initiatives. The coordinator develops and maintains internal quality data dashboards, provides analytical support, and reports trends and improvement opportunities to Quality leadership, stakeholders, teams, and committees. The role monitors new standards and changes to measure sets, educates key stakeholders on measure specifications, and serves as the liaison between outsourced abstraction services and platforms.

Requirements

Bachelor's degree in Nursing (BSN) to be acquired within three years of hire, or equivalent major/area of concentration in Nursing or Healthcare Quality.
Active RN licensure.
CPHQ (Certified Professional in Healthcare Quality) certification within two years of hire date.
Five years of recent clinical or hospital experience.
Effective interpersonal skills to maintain working relationships with professional and hospital staff on clinical quality measure performance.
Ability to educate leadership and frontline caregivers on clinical quality measures and performance.
Ability to define and measure quality processes and identify variation from accepted standards of practice, including patterns and trends.
Ability to leverage Adena's analytic environment to support data-driven decision-making and quality improvement initiatives.
Ability to direct activities supporting compliance with voluntary, mandatory, and contractual data acquisition, analysis, reporting, and improvement requirements.

Nice To Haves

Master of Science in Nursing (MSN).
Experience with EPIC navigation and chart review, Smartsheet, Excel, PowerPoint, and WebEx.

Responsibilities

Assist the Director of Infection Prevention and Quality Reporting Programs with regulatory reporting compliance.
Oversee clinical quality data abstraction for public and other reporting requirements across Adena hospital locations.
Support quality activities according to service-line, certification, regulatory, and initiative requirements.
Develop and maintain internal quality data dashboards; provide analysis and report trends and improvement opportunities.
Monitor changes to standards and measure sets and educate stakeholders on measure specifications.
Liaise between outsourced abstraction services and platforms.
Support required quality reporting programs, including CMS and TJC programs.
Access and manage the CMS Healthcare Quality Reporting (HQR) site and other submission and reporting portals, including submissions and verification during preview and validation periods.
Meet reporting deadlines and time targets to support compliance with reporting schedules and maintain Annual Payment Update (APU) payments; disseminate related reports.
Evaluate data integrity and monitor abstraction accuracy on an ongoing basis using interrater reliability, addressing opportunities identified.
Stay current on standards, measure specifications, professional practice guidelines, and regulatory requirements.
Develop and provide education to stakeholders as needed.
Recommend, participate in, and support multidisciplinary teams and educational sessions by providing updates or changes related to best-practice interventions.
Use performance and process improvement, project management, and change management methods to support operational and clinical quality initiatives and organizational goals.
Perform other assigned quality improvement and high-reliability duties.