Quality Stroke & Sepsis Coordinator - FT

Three Crosses Regional Hospital•Las Cruces, NM

4d•Onsite

About The Position

Three Crosses Regional Hospital is seeking a dedicated Quality Stroke & Sepsis Coordinator committed to clinical excellence and building a patient-centered culture. This role is responsible for coordinating and advancing the hospital’s Stroke and Sepsis programs, promoting evidence-based care, and ensuring compliance with accreditation, regulatory, clinical, and quality-reporting requirements. The Coordinator will serve as the organizational subject matter expert, collaborating with physicians, nursing, emergency services, ancillary departments, and Quality leadership. Key responsibilities include program oversight, clinical data abstraction and validation, performance monitoring, case review, survey readiness, and coordination of improvement initiatives. The position also involves attending Stroke and Sepsis activations to observe clinical response, provide feedback and real-time education, and conduct ongoing staff and provider education based on identified trends and requirements. The incumbent will analyze clinical outcomes, identify gaps in care, and work collaboratively with leaders to develop corrective actions. This role prepares reports for hospital leadership and committees and ensures accurate data submission to accrediting bodies, registries, and regulatory agencies, all while upholding the highest standards of ethical and professional conduct and supporting the hospital's mission, vision, and values.

Requirements

Associate degree in nursing from an accredited nursing program.
Minimum of three (3) years of hospital or acute-care nursing experience.
Current, unrestricted Registered Nurse license or multistate privilege to practice in New Mexico.
Current Basic Life Support certification.
Must meet all Employee Health and organizational onboarding requirements.

Nice To Haves

Bachelor of Science in Nursing.
Experience in Stroke, Sepsis, Emergency Services, Critical Care, Quality, clinical data abstraction, or performance improvement.
Stroke-related, Sepsis-related, quality, or clinical specialty certification.

Responsibilities

Serves as the primary coordinator for the hospital’s Stroke and Sepsis programs, ensuring compliance with applicable certification standards, regulatory requirements, clinical guidelines, and performance measures.
Leads Stroke certification and Sepsis program readiness activities, including documentation review, gap analysis, action planning, tracers, and follow-up monitoring.
Attends Stroke and Sepsis activations when on duty to observe the clinical response, promote adherence to established protocols, and identify opportunities for improvement.
Provides timely, constructive feedback and real-time education to physicians, nurses, and other members of the care team following clinical activations and case reviews.
Coordinates and performs accurate clinical data abstraction, validation, entry, and submission for Stroke and Sepsis measures, registries, and required reporting platforms.
Reviews medical records and supporting documentation to evaluate compliance with clinical pathways, treatment timeframes, documentation requirements, and established standards of care.
Monitors clinical performance measures and outcomes, including treatment timeframes, bundle compliance, complications, mortality, transfers, readmissions, and other established indicators.
Analyzes performance data and identifies trends, barriers, and opportunities for clinical and operational improvement.
Prepares reports, dashboards, case summaries, and performance updates for hospital leadership, medical staff, committees, clinical departments, and accreditation review.
Conducts and participates in case reviews, tracers, focused audits, and other performance-improvement activities related to Stroke and Sepsis care.
Collaborates with physicians, nursing leadership, emergency services, pharmacy, laboratory, radiology, respiratory therapy, informatics, education, and other departments to support timely, standardized, and coordinated care.
Works with department leaders and frontline staff to develop, implement, and monitor corrective actions and performance-improvement plans.
Develops and provides ongoing education and orientation for staff and providers regarding Stroke and Sepsis.
Participates in the development, review, and revision of Stroke and Sepsis policies, protocols, clinical pathways, order sets, and educational materials.
Coordinates Stroke and Sepsis committee activities, including meeting preparation, case presentation, data reporting, action-item tracking, and follow-up.
Collaborates with the Quality Data Analyst and Quality leadership to ensure data accuracy, integrity, and alignment with certification and regulatory requirements.
Maintains complete, organized, confidential, secure, and survey-ready program documentation, case files, educational records, and correspondence.
Participates in Stroke certification surveys, program reviews, and required follow-up activities.
Remains current with changes in certification standards, CMS requirements, evidence-based clinical guidelines, and applicable regulatory expectations.
Serves as a resource to clinical teams and promotes a collaborative, nonpunitive approach to case review, education, and continuous improvement.
Attends meetings, committees, and workgroups related to the Stroke and Sepsis programs, as assigned.
Performs other duties as assigned.