About The Position

A registered nurse who oversees the following components of the Quality Management Program at University of Michigan Health-Sparrow: BCBSM/BCN Collaborative Quality Initiatives (CQIs), Clinical Data Registries, and Inpatient Quality Reporting including Centers for Medicare and Medicaid Services (CMS) Core Measures, Electronic Clinical Quality Measures (eCQMs), and The Joint Commission (TJC) data submissions, if applicable.

Requirements

  • Graduate of an accredited school of nursing
  • Bachelor’s degree in nursing
  • Current Michigan R.N. license.
  • Minimum of three (3) years of experience with collaborative quality initiatives, clinical data registries, and/or core measures required.
  • Skill and proficiency in applying performance improvement principles and concepts.
  • Advanced communication and interpersonal skills with all levels of internal and external customers.
  • Knowledge of relevant computer software and hardware applications.
  • Self-motivated, able to work independently, make decisions and take appropriate action when concerns arise.
  • Ability to work with sensitive and/or confidential information.
  • Ability to make effective decisions, judgment, and incorporate problem-solving techniques.
  • A high degree of professionalism is essential for all contacts with others.

Nice To Haves

  • Master degree in nursing is preferred

Responsibilities

  • Provides oversight for the Collaborative Quality Initiative portion of the BCBSM/BCN Value Partnership Program.
  • Maintains current knowledge of the CQIs, requirements for participation, annual performance criteria, and Pay-for-Performance program.
  • Works collaboratively with physician champions, CQI coordinating centers, and outside vendors to ensure that goals are met.
  • Attends collaborative meetings as required.
  • Participates in/facilitates quality initiative meetings as needed.
  • Reviews data related to performance measures to identify areas for improvement.
  • Reports performance improvement data from CQIs and clinical data registries as indicated.
  • Oversees the mandated reporting requirements for Centers for Medicare and Medicaid Services (CMS) Core Measures and Electronic Clinical Quality Measures (eCQMs), including required data submissions for The Joint Commission, if applicable.
  • Maintains current knowledge of, and compliance to, reporting requirements.
  • Understands applicable regulations.
  • Maintains awareness of current data trends and best practices.
  • Recommends system changes to improve performance and patient safety where appropriate.
  • Provides direction and mentorship for quality coordinators and decision support staff responsible for the CQIs, clinical data registries, core measures, and eCQMs, including participating in recruitment and selection of staff, providing/coordinating staff orientation and development opportunities, meeting regularly with assigned staff, enabling accurate and timely data abstraction, and supporting staff to meet annual performance goals.
  • Monitors the success of performance improvement and quality activities via key process and outcome variables.
  • Reports performance improvement data related to Quality Department activities as indicated.
  • Maintains current knowledge of quality management principles including data collection and measurement, analysis, improving reliability, engaging stakeholders, project management, and PDSA.
  • Reviews and updates policies and procedures related to Quality Management activities.
  • Supports and works collaboratively with members of the Quality Team.
  • Works closely with E.D.I.S and H.I.T.S. to implement electronic file support of clinical data to reduce the burden of manual data abstraction, analysis, and reporting.
  • Recognizes and rewards individuals and groups for their efforts in the areas of performance improvement, and utilization of best practices.
  • Promotes a non-punitive culture of service excellence, continuous quality improvement and patient safety.
  • Performs other duties as assigned, including maintaining current knowledge of department processes, protocols and procedures, pursuing self-directed learning and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management.
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