Title: Clinical/RN Mgr./Continuous Quality Improvement Mgr.
Reports To: Dir. Of NDHC & Facilities Mgmt.
Physical Requirements: Normal Office Environment
Hours of Work: Full-time, 37.5 hours per week
Days, Flexible schedule needed
and/or equivalent experience.
- Bachelor’s Degree in Nursing or other Health Care field(i.e. Human Services)
- Registered Nurse with minimum three years experience.
- Minimum three years prior experience in a Quality Improvement related role in a Hospital, Regulatory agency or outpatient clinic setting involving medical services
- Minimum three years experience supervising in a quality improvement department
- Basic computer skills are preferred, experience with electronic medical records is a plus.
- Must be able to read and write the English Language
- Valid NYS Driver’s License
Essential Duties and Responsibilities:
- The duties of this position include but are not limited to the hiring, termination, discipline, supervision and scheduling of direct reports.
- Facilitate the development and implementation of a written Quality Improvement Program that includes a planned and systematic process for monitoring and assessing the quality and appropriateness of patient care and clinical performance on an ongoing basis.
- Establish review criteria in accordance with current standards of professional practice for monitoring and assessing patient care and clinical performance.
- Conduct periodic medical record reviews for all disciplines and focused reviews as appropriate and as requested.
- Communicate on an ongoing basis to the Medical Director, Continuous Quality Improvement Committee, and Directors any issues pertaining to quality occur.
- Coordinate the Peer review process, which includes development of the process, ongoing evaluation and make changes as need dictates under the direction of the Medical Director and in compliance with the Department of Health.
- Direct Supervision of the Licensed Practical Nurse and Medical assistant assigned to the Medical Department, Direct supervision of CQI administrative assistant, Supervision of staff/providers as assigned.
- Ensure the development, review, and revisions of Medical Clinical Protocols. Evaluate on an ongoing basis, the efficiency and coordination of clinical services from the perspective of meeting the clinical treatment needs of the patients seen in the Primary Medical and Medical Specialty clinics.
- Develop and/or revise existing policies and procedures to ensure compliance with DOH, OSHA, CMS, and all other applicable regulations. Continue existing relationships with DOH and appropriate consultants to obtain any necessary clarifications.
- Ensure compliance to track all staff Pre-employment and Annual Health requirements and report to the Director areas of concern.
- Develop, implement and evaluate the Infection Control Program on an ongoing basis. Ensure assigned staff conducts infection control surveillance. Conduct ongoing committee meetings to discuss issues pertaining to Infection Control and that the Director is made aware of risks identified.
- Coordinate the Appointment and Reappointment of Medical, Dental, Podiatry, and allied health practitioners with Clinical Privileges. This includes coordinating the ongoing Credentialing Committee, and discussions with the Medical Director on matters pertaining to the appointment and reappointment of these professionals. Coordinate credentialing with insurance companies for providers as needed.
- Coordinate the Physician Profiling process to ensure data collected is communicated and reviewed at the time of reappointment and approval of clinical privileges.
- Chair of Safety Committee, prepare and coordinate meeting agenda items. Coordinate the fire drills and disaster drills with Facilities Management staff. Consult with Liberty Safety Manager on current, revised, and new regulations.
- Schedule and coordinate pre-employment and annual training for new and existing staff. Ongoing evaluation and revision to the training curriculum.
- Prepare reports for all components of the CQI Program to facilitate the communication of CQI information to appropriate committees and the Board as requested by the Director.
- Ensure that areas of risk identified through the CQI process are communicated to the Director and other appropriate staff as directed.
- Ensure all incidents, such as staff injury accidents, unusual occurrences, medication events, and Patient Complaints are reviewed and action is taken as appropriate and that these events are reported to the CQI Committee and the Medical Director and Director.
- Ensure the review of cases pertaining to quality and documentation issues are communicated to the Director and the Medical Director as appropriate and a peer review is conducted when requested by the Medical Director.
- Review assigned web sites for the review of updated memorandums from the NYSDOH, OMIG, OIG, as well as Medicaid updates, and conduct research as requested on changes in rules and regulations.
- Coordinate the onsite mandated consultant visits such as the Medical Record Consultant, Pharmacist, and Infection Control, as requested and ensure any areas of concerns are addressed as appropriate.
- Coordinate patient satisfaction surveys and report results up to the CQI Committee, Directors, and Board.
- Provide person centered attention to all patients
- Understand and implement the principles of PCMH
- Oversee Health Center Operations including: Delivery of Health Services, Provider Relations, Utilization Management, Practice Management, Business Operations
- Direct the delivery of Health Services including Primary Medical and Medical Specialties in conjunction with the Medical Director, Chief of Dentistry, and the Director of the Health Center and Facilities Management
- In conjunction with the Business Office and the Director of the Health Center and Facilities Management, review and monitor Health Center Budget, Reimbursement Management, Financial Reporting and Billing and Collections.
- Negotiate agreement/contracts with medical, dental, and clinical providers. Assist in recruitment of providers as necessary.
- Review and monitor the Dental and Medical Operations to identify operational and quality areas of improvement and efficiencies.
- Participate and Chair CQI committee, Infection Control Committee, Credentialing Committee, Safety committee and any other committees as assigned by the Director of the Health Center and Facilities Management.
- In conjunction with the Director of New Dimensions in Health Care and Facility Management, carry out the mission of the Health Center to provide person centered services to people with disabilities and provide access to dental and medical care in those communities and individuals with an identified need.
- Work with the Board president and Director of New Dimensions in Health Care and Facility Management to set the agenda for monthly Board meetings. Prepare and present agenda detail, as necessary, for Board review and discussion.
- Monitor and ensure standards are met for Meaningful Use and Patient Centered Medical Home.
- Participate with other caregivers and other entities in the Community to improve and ensure continuity of care for patients.
- Provide application support on Greenway software to staff across all functional areas, identifying, prioritizing and resolving user problems.
- Work with staff on assuring compliance with quality measures (MU- run weekly report and identify significant changes. Develop and implement plan to ensure meaningful use measures are being met. PQRS, PCMH- assist in development and training of new policies).
- Complete provider and staff enrollment and disenrollment functions involving the use of the Greenway software. Assisting staff/providers with password changes and with solving issues related to Greenway software. Administering rights to users as appropriate.
Disclaimer – The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Liberty reserves the right at its sole discretion to amend its policies, programs and/or guidelines, including the contents of this job description, at any time without prior notice.
We are proud to be an Equal Opportunity/Affirmative Action Program Employer, Minority/Female/ Disabled/Veteran. We maintain a drug-free workplace and perform pre-employment physicals and substance abuse testing.