Job Description

Director (RN) Quality Assurance

Mimbres Valley Medical Center is your community medical provider, serving southwestern New Mexico area and its residents with inpatient, outpatient, medical, surgical, diagnostic and emergency care. We are your family, friends and neighbors, and we work with and for our community to provide quality healthcare that fits your life and lifestyle.

We’re making a difference in our friends’ and families’ lives; if this is something you believe in, we would like you to join our team.

• Facilitates alignment between improvement initiatives and the organization’s strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
• Responsible for maintaining the facilities system-wide Quality program; to include data collection, aggregating and analyzing data, maintaining policies and procedures, and reporting to administrators, Medical Staff, and the Board.
• Works closely with Clinical and Non-Clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets identified by Hospital leadership.
• Serves as an internal consultant to administration, staff, and physicians in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.
• Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
• Coordinate, manage and report Core Measures, ACO/MIPS/MACRA and meaningful use measures and other quality metrics as assigned.
• Collects and reports HCAHPS data for the facility.
• Organize all Quality Management meetings, maintain minutes and make recommendations to the committee based on best practice and current regulatory standards.
• Conduct internal audits and risk analysis as determined by the Quality Committee.
• Participate / Coordinate in nursing and physician peer review processes and chart reviews, as necessary.
• Mange and support physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, scorecards, quality metrics, etc.
• Analyzes all assigned areas for opportunities of improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality ie: Core Measures, Hospital Acquired Conditions, etc.
• Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, efficiency, etc. using available information systems data. Where other data is necessary but not readily available, will design and implement appropriate data collection. Uses data from appropriate external sources, including comparative databases.
• Manages performance improvement projects, flow and alignment to assure milestones and key performance indicators are met within defined parameters. Documents the results of projects, and submits other documentation as requested.
• Participates in the Grievance Committee and works with department leaders to resolve investigations within the incident reporting system.
• Evaluate and document the effectiveness of the quality management system.
• Design, coordinate and maintain various aspects of the patient safety and risk management programs for all of the Hospital and its affiliated clinics.
• Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury. Recommend interventions which will enhance the safety and well-being of patients, staff and organization at large.
• Mobilize departmental or administrative support to address unresolved high-risk practices.

Qualifications:

• Registered Nurse preferred.
• 3+ years experience in a hospital facility required, Quality/Risk leadership experience, preferred.
• Master’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical base, preferred.
• CPHQ (Certified Professional in Healthcare Quality), preferred
• Travel is infrequent.
• Understanding Healthcare
• Strong accounting knowledge and experience.
• Good communicator.
• Excellent in Excel (pivot tables, V-lookup’s, etc.)
• Critical thinking and problem-solving abilities.

Benefits:

• Competitive salary and benefits package.
• Opportunities for professional development and advancement.
• Supportive work environment with a collaborative team.
• Comprehensive healthcare coverage.
• Retirement savings plan.
• Paid time off and flexible scheduling options.
• Student loan repayment program.

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