The Quality Measures Coordinator is responsible for the coordination of activities and processes aimed at assuring compliance with federally mandated hospital and clinician regulatory measure objectives. The Coordinator evaluates adherence to compliance standards and maintains documentation for regulatory auditing. The Coordinator collaborates with internal departments to ensure data integrity and ongoing performance improvement activities.
Coordinates the planning and execution of activities and processes related to regulatory measures throughout the organization
- Maintains current knowledge of regulatory measures and applicable clinical practice guidelines
- Identifies and manages the escalation and resolution of activity/process issues
- Serves as a resource for all activity/process related questions and inquiries by the organization
- Coordinates, monitors, validates and reports performance/compliance status with regulatory measure objectives throughout the organization
- Analyzes, validates, and reviews reports to evaluate adherence to compliance standards
- Partners with Providers and staff to review individual performance related to regulatory
- Coordinates and maintains supportive documentation to demonstrate evidence of compliance with regulatory requirements
- Collaborates with the IS department and ancillaries to ensure that the processes for capturing data from the electronic health record supports attestation of the regulatory measure initiatives
- Develops and analyzes system-generated reports on EHR system data
- Effectively coordinates with IS staff to improve efficiencies and usability with the EHR
- Collaborates with clinical information staff to ensure current and future stages of MU are built to support end user utilization
- Ensures solution database integrity
- Coordinates and maintains supportive documentation for regulatory measure audit files
- Coordinates activities to maintain audit files
- Gathers and archives supportive documentation to demonstrate evidence of compliance with regulatory requirements
- Coordinates and submits audit responses
- Works with performance improvement management to develop and monitor plans for
organizational performance improvement functions
- Coordinates data reporting and performs analysis to support performance improvement and department compliance
- Provide ongoing education to end-users on regulatory measure initiatives to align outcomes and performance metrics with regulatory measure requirements
- Assists with assessment of end-user workflows/processes to ensure compliance with regulatory measures
Qualification and Education Requirements
- Required education – Bachelor’s Degree – Nursing, Business, Public Health, Healthcare Management, Informatics or other field of study
- Preferred education – Master’s degree – Related field
License or Certification Requirements
- Required Licensure: Current MS licensure as indicated by profession
- Required Certification: Certified Healthcare Quality Professional (CPHQ)
- Required – Three (3) years of experience in a healthcare setting supporting performance improvement or quality management projects or three (3) years of experience managing complex electronic health record projects
- Preferred – Five (5) years of clinical experience in an acute hospital setting with experience in Informatics and Clinical Information Systems
Core (Career Level) Competencies
Profile: S2 – Relies on a degree of professional experience. Still acquiring higher-level knowledge and skills.
Knowledge: S2 – Utilizes general industry knowledge and professional experience in the application of concepts, principals, and technical capabilities to perform varied tasks.
Complexity: S2 – Works on projects of moderate scope and complexity; applies judgment within defined parameters.
Autonomy: S2 – Receives general guidance; may receive more detailed instruction on new projects. Work reviewed for sound reasoning and accuracy.
Interaction: S2 – Exchanges information on routine and non-routine matters.
Required Education: S2 – Bachelor’s degree or equivalent experience.
Required Experience: S2 – Years of relevant experience required: 2. Preferred minimum years of relevant experience: 2-4.
Core (Position Level) Competencies
- Advanced clinical knowledge regarding disease management
- Proficient in Microsoft Office applications
- Advanced clinical knowledge regarding disease management
- Financial and clinical analytical skills
- Work collaboratively with diverse constituents including staff, leaders, medical staff, residents, patients, and the community
- Organize and effectively coordinate multiple and frequently conflicting concurrent tasks with excellent follow-through
Work Environment and Physical Requirements
Work is generally performed in a healthcare environment. Exposure to chemicals which may be used in patient care.
Frequent reaching, sitting, walking, and standing may be required. No special coordination beyond that used for normal mobility and handling of everyday objects and materials is needed to perform the job.
Section 503 – 41 CFR Part 60-741, and VEVRAA (Part 60-300) – EEO and Reasonable Accommodation Online ATS Statement
Memorial Hospital at Gulfport is an equal opportunity employer and, as such, affirms in policy and practice to recruit, hire, train, and promote, in all job classifications, without regard to race, religion, color, national origin, citizenship, sex, sexual orientation, gender identity, age, veteran status, disability, genetic information, or any other protected characteristic. Memorial Hospital at Gulfport will not discriminate against persons because of their disability, including disabled veterans, and will make reasonable accommodations for known physical or mental limitations of qualified employees and applicants with disabilities. If you are interested in applying and require special assistance or accommodations due to a disability please contact our Human Resources department at 228-865- 3081 or email Accommodations@mhg.com.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.