MAJOR FUNCTION:

ESSENTIAL FUNCTIONS:

• Participates and initiates activities to support Joy In The Workplace throughout the quality department specifically (and the organization as a whole).
• Oversees the implementation of the Quality Improvement, Quality Assurance (Qi/QA) and risk management program [Continuous Quality Performance and Risk Management - CQPRM Plan] at HJAHC and ensures QI/QA and risk assessments are conducted.
• Reports regularly on all CQPRM activities to the board of directors through the Health Services subcommittee of the board of directors.
• Oversees and ensures reports on quarterly quality and risk assessments and an annual quality and risk management reports working with the organizations Risk Manager.
• Responsible monitoring QI/QA outcomes and for knowing current QA regulations and informing the CEO of any new and/or revised regulations imposed.
• Responsible for creating and updating QI/QA Standard Operating Procedures.
• Assists departments with the coordination of audit information, and recommends appropriate data-gathering mechanisms, procedures, etc. 
• Attends meetings as requested, in particular the monthly QPAIC meeting at which the DQI serves as recorder and coordinator.
• Assists the CEO with revisions to the CQPRM plan for board and staff review.
• Gathers information and documentation about unusual occurrences; assists with the identification of problems through statistical information, monitoring, and reporting results of action taken to reduce risks to patients. Provides information to employees and visitors when necessary.
• Actively participates in health quality initiatives and the development of programs surrounding new models of health care, internally and as appropriate in the Trenton community.
• Performs other duties as assigned by the CEO.

PHYSICAL DEMANDS

• Work is varied in nature and is performed with frequent interruptions. Work requires close attention to detail and accuracy. Occasional mental stress is involved in completing QA activities with regard to physicians and departments and interrelationships.
• Work requires sitting, standing, and/or walking, moving and reading for periods of three hours or more.

KNOWLEDGE, SKILLS AND ABILITIES

• Knowledge and understanding of the coding abstracting system used in the Medical Records Department for efficient data gathering.
• Knowledge of accreditation standards applicable to the medical staff. QPAIC committee activities and Medical Records Department.
• Ability to interpret Medical Records policies and procedures and to apply them in specific situations.
• Thorough knowledge of Joint Commission quality-assurance requirements.

EDUCATION

• Bachelors or Master’s degree preferred and current licensure, as applicable, in nursing, public health or equivalent.
• A minimum of five-seven years’ related work experience in quality management, risk management areas.
• Demonstrated successful supervisory experience of three-five years required.
• Some practical experience in the field; knowledge of medical diagnoses and treatment helpful.