Quality Compliance Auditor- Full Time
: Job Details :

This position requires the auditing and analysis of specific quality measures and issues for compliance with regulatory, public reporting and pay for performance requirements. This position will serve as an active member of committees and work process teams to assist with implementation, monitoring and reporting of improvement goals that provide quality patient care and optimal outcomes. This position will oversee current and future federally mandated quality initiatives.Essential Functions- Provides in-depth reviews of patient charts.- Works closely with, and supports the Infection Preventionist and Quality Review nurses.- Runs reports as needed and by assigned deadlines.- Reviews and abstracts data from patient medical records to facilitate federally mandated reporting requirements, pay for performance quality measures and reports of hospital compliance with regulatory standards.- Assists with The Centers for Medicare and Medicaid Services (CMS) and State continuous readiness through review of recent changes.- Analyzes data, generates reports and tracks performance improvement on quality goals and indicators.- Analyzes performance data and makes recommendations to leadership to improve processes and performance to achieve goals for federally mandated quality care measures- Provides education to hospital and medical staff on current and upcoming quality initiatives.- Provide medical staff and hospital staff with research articles for evidence-based practices.- Presents analytical data, research and reports to work process improvement teams and medical staff committee meetings.- Corresponds and meets with medical staff to review quality data, quality measure goals and compliance or non-compliance with regard to specific quality indicators.- Oversees regulatory rounding by directors and Quality staff.- Super user for QualityNet, Press Ganey, RL Datix, and other programs as required.Other Duties- Attends off site educational conferences and seminars related to quality and patient safety.- Participates in departmental and association wide informational meetings and inservices, including staff meetings, association wide forums, and seminars.- Reviews department and association wide policies and procedures annually. Develops and maintains new policies and procedures as needed.Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.Abilities- Must be able to read, write, understand, and speak English.- Operational knowledge of equipment in the Quality Management department (fax, printers, copy machine, phone systems)- Proficiency in computer programs, including Microsoft Office, email, internet, QualityNet, CMS/government websites, National Healthcare Safety Network (NHSN), and Hospital Information Systems.- Service-oriented with excellent customer service skills.- Strong computer skills.- Excellent organizational skills and multitasking abilities.- Professional interpersonal skills.- Strong time management and prioritization abilities.- Exceptional telephone etiquette.- Excellent decision-making skills with minimal direction.- Ability to obtain working knowledge of federally mandated quality programs and initiatives.Supervisory ResponsibilitiesNone.Work EnvironmentAt Summit Healthcare, our mission statement is that we are trusted to provide exceptional, compassionate care close to home. Our vision is to be the healthcare system of choice.To uphold our mission and vision statements, we expect all employees to practice SHINE Behavioral standards:- Always SHINE - show respect and be kind.- Always work together - we are on the same team.- Always serve others - no job is beneath you.- Always maintain high standards of quality and safety - best practice every time.- Always communicate clearly - be compassionate.- Always practice integrity - maintain confidentiality.- Always be accountable - take responsibility.- Always empower - create an environment of success.- Always excel - don't settle for mediocrity.- Always promote wellness - make choices for a healthy lifestyle.Physical DemandsExerts up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and/or a negligible amount of force constantly to move objects. Physical demands are in excess of those of Sedentary work. Light work usually requires walking or standing to a significant degree. Worker is exposed to extensive computer work.Required Education and Experience- 1 year of experience in healthcarePreferred Education and Experience- Bachelor's of Science in Nursing (BSN).- 1 year of experience in healthcare quality.OSHA Exposure Category:Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues and are not a condition of employment.This is a safety sensitive position.