Coordinator Quality Reporting Programs-ARMC(Days)FT

Adena Health•Chillicothe, OH

About The Position

The Coordinator Quality Reporting Programs supports Adena Health’s quality reporting and improvement work across its hospital locations. In a High Reliability Organization, the coordinator reports to and assists the Director of Infection Prevention and Quality Reporting Programs in maintaining compliance with regulatory reporting requirements, including CMS and The Joint Commission (TJC) programs. The position oversees clinical quality data abstraction for public and other reporting requirements and supports quality activities according to service-line, certification, and regulatory requirements and initiatives. The coordinator develops and maintains internal quality data dashboards, provides analytical support, and communicates trends and improvement opportunities to Quality leadership, stakeholders, teams, and committees. The role monitors new standards and measure-set changes, educates stakeholders on measure specifications, and serves as the liaison between outsourced abstraction services and platforms. The position is based in Chillicothe and is full-time, day shift.

Requirements

Bachelor’s degree in Nursing (BSN), to be acquired within three years of hire, or equivalent; major or area of concentration in Nursing or Healthcare Quality.
Active RN licensure.
CPHQ 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 guide data-driven decision-making and quality improvement initiatives.
Ability to direct activities supporting compliance with voluntary, mandatory, and contractual reporting requirements for data acquisition, analysis, reporting, and improvement.

Nice To Haves

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

Responsibilities

Support required quality reporting programs, including CMS and TJC.
Access and manage the CMS Healthcare Quality Reporting (HQR) site and other submission and reporting portals, completing submissions and verification during preview and validation periods for hospital reporting programs across the system.
Meet reporting deadlines and time targets to maintain Annual Payment Update (APU) payments, and distribute related reports.
Evaluate data integrity and monitor abstraction accuracy on an ongoing basis using interrater reliability, while addressing opportunities identified.
Monitor changes in standards, measure specifications, professional practice guidelines, and regulatory requirements.
Develop and provide education to stakeholders as needed, including education on clinical quality measures, performance, and measure specifications.
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, improve performance, and achieve organizational goals.
Develop and maintain internal quality data dashboards, provide analytical support, and report trends and improvement opportunities to Quality leadership, stakeholders, teams, and committees.
Oversee duties associated with clinical quality data abstraction for public and other reporting requirements across Adena hospital locations.
Serve as liaison between outsourced abstraction services and platforms.
Perform other quality improvement and high-reliability duties as assigned.