Since 1875, South Brooklyn Health has established its reputation for clinical excellence and culturally competent care. It has designations as a Certified Percutaneous Coronary Intervention (PCI) Center, an Advanced Primary Stroke Center, an accredited Baby-Friendly Hospital, a U.S. News & World Report high performing hospital. The hospital's staff is as diverse as the patients they serve. Interpreter services can be provided at any time of the day or night in over 130 languages. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons. Work Shifts 8:00 A.M - 4:00 P.M Job Description Purpose: Under the general supervision of the Associate Director for Quality Management, the Coordinating Manager B -Clinical Chart Reviewer provides guidance and support to multidisciplinary teams of healthcare professionals related to Hospital-Wide Quality, Performance Improvement, Regulatory compliance and Patient Safety activities. Provides ongoing medical record reviews/data abstraction for quality of care indicators as defined by regulatory agencies including, but not limited to: TJC, CMS, DOH, NSQIP, and voluntary regulatory bodies and quality reporting programs. Specific Duties and Responsibilities: The Coordinating Manager B [Clinical Chart Reviewer is charged with and responsible for:
Serves as the Departmental lead for various core measures data abstraction, monitoring, analysis, and presentation: Performs the required number of monthly medical record abstractions as assigned and according to the schedule determined by the Associate Director. Performs accurate and timely entry of data into the designated website or database, and assures the transmission of completed and accurate data, within the desiY1ated deadline. Abstractions may include, but are not limited to the following measures: Outpatient ED Influenza Immunization (IMM-2) CMS sepsis (SEP-I) VTEDOH sepsis ED quality monitors and checklists Inpatient quality monitors and checklist Ml Total Hip/Total Knee Replacement Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Perinatal Care 1-6: Elective Delivery, Cesarean Birth, Exclusive Breast Milk Feeding, and UnexpectedComplications in Term Newborns. HBIPS Discharge: Violence Risk, Substance Use, Trauma, Patient Strength Screening, and Multiple Antipsychotics Medications at Discharge with Appropriate Justification Global-IPFQR: Influenza Immunization, Alcohol Brief Intervention, Tobacco UseTreatment, Screening for Metabolic Disorders, Transition Record with Specified Elements Received by Discharge Leapfrog measures Conducts concurrent chart reviews for the stroke program and other programs requiring time-sensitive data abstraction. Reviews/edits/corrects/revises Fall-Out Report before data submission. Ensure accurate data reporting for abstractions and quality measures with no less than 95% inter-rater reliability. Responsible for identifying opportunities for quality improvement, through analysis of data, and will be responsible for facilitating such opportunities for improvement in collaboration with key stakeholders. Provides feedback to clinicians and program coordinators based on reviews and findings. Analyzes quality indicator reports and develops presentations to leverage core measure data for use in hospital-wide quality improvement efforts. Attends meetings and acts as an educational resource regarding the quality measures program. Prepares data reports for Departmental meetings and leaders in an effective way and presents to stakeholders Leads and coordinates team meetings to discuss data analysis and improvement needs. Participates in audits conducted by regulatory agencies i.e. DOH, CMS, TJC Provides Quarterly Reports to Central Office QAPI Board Report Submits inquiries for clarification to Premier/DOH/CMS/ IPRO/NSQIP as needed. Identifies patients for inclusion in quality databases, based on program protocol, collects compliance and audit data for the program through the effective utilization of the hospital medical record system and audit tools, and provides feedback on data to staff to drive improvement. Contacts patients and/or families by telephone and/or written correspondence to record data of any relevant occurrences, associated with quality programs Meets quality program caseload accrual requirements with weekly completion benchmarks set by the supervisor to meet the needs of the organization Successfully complete Training/Certification for quality programs and annual competency certification and continuing education requirements Serves as a resource to the organization for Quality, Regulatory compliance, and Patient Safety. Facilitates data collection responsibilities for Value-Based Purchasing and other publicly reported indicators and other measures as determined by NYC Health + Hospitals or the Performance Improvement Committee. Participates in onsite visits from regulatory agencies as needed. Participates in root cause analysis and proactive risk assessment processes as required Contributes to an information database of continuous compliance and patient safety issues for planning, priority setting, analysis, and trending. Participates in completing South Brooklyn Health's Quarterly Report to the Governing Body and other NYC Health + Hospitals reports as required, ensuring all entries are accurate and following up on outstanding reports. Provides and assists with interpretation and education of TJC standards/intent. Performs regulatory mock tracer activities as assigned. Manage, coordinate, and monitor data collection and analysis on performance improvement, patient safety, and continuous compliance-related issues as appropriate. Assist in assessing organizational compliance with accreditation standards and regulations. Helps identify areas of vulnerability related to continuous compliance, performance improvement, and patient safety. Assists in developing strategies and corrective actions to enhance continuous compliance and patient safety. Support the process of identifying staff training needs and assist as appropriate in developing effective employee education programs to enhance continuous compliance. Develop and provide presentations as needed/assigned. Perform all duties in alignment with the mission, vision, values, and behavioral expectations of NYC Health + Hospitals Other duties as assigned. Minimum Qualifications 1. A Master's degree from an accredited college or university in Public Health, Public Administration, Business Administration, Social Work, Psychology or Rehabilitation Counseling; and 2. Two (2) years of full-time experience in medically-oriented health care and medical support systems environment, one (1) year of which included experience in an administrative or supervisory capacity in such occupations as physical, occupational, inhalation, speech and audiology therapy or as Medical/Laboratory Technologist, Microbiologist (various specialties), Chemist (biochemist), Radiation and X-Ray Technician; or two (2) years of responsible level experience in business management systems or general administration including one (1) year in a supervisory or administrative capacity; or 3. A Baccalaureate degree from an accredited college or university in disciplines listed in 1 above; and 4. Three (3) years of full-time experience, as described in 2 above, including two (2) years of experience in an administrative or supervisory capacity in occupations, as listed in 2 above; or 5. A satisfactory equivalent combination of education, training and/or experience. NYC Health and Hospitals offers a competitive benefits package that includes: • Comprehensive Health Benefits for employees hired to work 20+ hrs. per week • Retirement Savings and Pension Plans • Loan Forgiveness Programs for eligible employees • Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts • College tuition discounts and professional development opportunities • Multiple employee discounts programs • Note: Certification or licensure may be required.