Job description

Tri-City Healthcare District has been serving the North County region for almost 60 years and remains committed to providing high quality healthcare and community services for every individual we encounter regardless of race, color, ethnicity, gender, sexual orientation, disability or socioeconomic status.

Our mission is to advance the health and wellness of the community we serve. In order to achieve our mission, we see, hear and listen to our front line healthcare workers, employees, medical staff and all community stakeholders in order to understand and meet our community’s needs.

Position Summary:

This position will assist the Quality in monitoring all quality activities of the hospital in accordance with accreditation, regulatory and other requirements. Supports the timely/accurate collecting, submitting and reporting process and outcome data on patient populations as determined by hospital and departmental leadership. Some of which may include mandated clinical projects by CMS, The Joint Commission or other regulatory agencies. Acts as a mentor and coaches staff to ensure quality outcomes, assist managers and staff to create actionable ideas for improvement and to limit variability in performance. Assists in preparation of dashboards and graphs to track and trend organizational metrics for quality improvement and internal/external reporting. This individual meets with the Quality Director and Quality Leaders on a regular basis and participates in committees as assigned to improve practice and patient care. Analyzes information and identifies key issues that meet the criteria and measures set forth from the Quality Assurance/Performance Improvement and Clinical Quality Committees. Requires collaboration with nursing informatics and department educators to understand clinical workflow to improve outcomes/patient safety. The individual should have comprehensive and advanced clinical knowledge, data analysis and performance improvement experience as well as strong organizational skills.

Major Position Responsibilities:

The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.

• Maintains a safe, clean working environment, including unit based safety and infection control requirements.
• Retrospective/Concurrent Medical Record review/abstraction and vendor oversite.
• Inter-Rater Reliability of abstracted measures.
• Identify gaps and drive performance improvement with both eCQMs/CQMs.
• Analyzes reports, identifies and communicates important findings, enters results into appropriate database. Thoroughly understands organization quality improvement initiatives as they relate to our regulatory reporting and reimbursement.
• Communicates effectively with targeted staff and physicians to implement changes in documentation, clinical practice and behavior as indicated by results of medical record reviews.
• Monitor need for updates in accordance with regulatory, accreditation changes and facility needs.
• Develops and presents meaningful reports with analytical summary for departments, committees and staff.
• Performs ad hoc audits, special studies, or other quality analysis activities and collaborates with organizational leaders to present analytical summary.
• Applies, understands and follows Regulatory Reporting standards/guidelines, Hospital Rules and Regulations, Hospital Policies and Procedures, Title 22; Joint Commission Standards, Medicare Conditions of Participation.
• Participates in other initiatives and programs and performs other duties as assigned by the Department Leader.
• Responsible to maintain confidentiality of sensitive information.
• Evaluates and presents information in a professional manner.

Qualifications:

• Minimum 5 years of healthcare quality experience. Will consider 2 years of healthcare/clinical coding with 2 years of performance improvement experience, required.
• Understanding of regulatory requirements, performance improvement methodology, required.
• Ability to facilitate clinical groups to review performance improvement data and develop/implement specific actions resulting from the review of information.
• Proven ability in organizing, analyzing, and synthesizing quantitative and qualitative data, required.
• Ability to motivate, teach and coach Clinical and Non-Clinical leaders, frontline staff for Process Improvement methodologies.
• Adept at learning the Six Sigma, and Lean Methodology tools for process improvement.
• Ability to understand and apply Hospital Rules and Regulations, Hospital Policies and Procedures; Title 22; Joint Commission Standards; and Medicare Conditions of Participation, required.
• Excellent oral and written communication and interpersonal skills, required.
• Experience working with sensitive information and maintaining confidentiality, required.
• Demonstrated knowledge of clinical applications, Word, Excel, PowerPoint, Outlook, Visio required.
• Proficiency in electronic medical record systems, required. “Cerner” electronic medical record system knowledge, preferred.
• Strong computer database skills, preferred.
• Ability to work effectively in a team environment, required.
• Knowledge of regulatory and accreditation standards, required.
• Ability to manage databases and retrieve, analyze, summarize, and present information effectively, required.
• Ability to collaborate and work with Subject Matter Experts involved in Process Improvement Initiatives required.

Education:

• Graduate of an accredited school of nursing with a Bachelor’s in Nursing or Bachelor’s/ Degree in a Healthcare related field, required.
• Bachelor’s or Master’s degree in information systems or health care management, preferred.

Licenses:

• CA RN license, preferred.

Certification:

• Certified Professional in Healthcare Quality (CPHQ) required or must obtain within 24 months from hire date, required.

Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.

*Salary/Hourly Wage range based on experience.

To protect the health of patients and staff, and to comply with the new State of California mandates, all job offers are contingent on the successful engagement in the TCMC COVID-19 vaccination program (fully vaccinated with documented proof or approved exception/deferral.)

TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.

Job Type: Full-time

Pay: $71,000.00 - $95,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible schedule
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Ability to commute/relocate:

• Oceanside, CA 92056: Reliably commute or planning to relocate before starting work (Required)

Experience:

• healthcare quality: 5 years (Required)
• healthcare/clinical coding: 2 years (Preferred)
• performance improvement: 2 years (Preferred)

License/Certification:

• CPHQ (Preferred)

Work Location: In person

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