About this role
Job Summary
Supports quality improvement, patient safety, regulatory compliance, accreditation readiness, and required clinical quality reporting. Performs record review, data abstraction, auditing, analysis, education, and coordination of improvement activities.
Essential Functions
- Performs patient record review, data abstraction, validation, and timely submission for required quality and regulatory reporting.
- Conducts audits and analyzes quality, safety, documentation, process, and patient experience data; communicates findings and recommendations.
- Supports regulatory compliance, accreditation readiness, policy review, and corrective action monitoring.
- Facilitates multidisciplinary quality improvement initiatives using recognized improvement methods and tracking tools.
- Collaborates with providers, leaders, and staff to evaluate workflows, implement improvements, and monitor outcomes.
- Provides education and technical support related to quality measures, documentation, compliance, and improvement activities.
- Promotes a culture of patient safety, accountability, and continuous improvement.
- Completes other duties as assigned in support of Summit Healthcare's Quality Management initiatives and organizational goals.
Other Duties
- 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
- Knowledge of healthcare quality improvement, patient safety, regulatory compliance, accreditation, and clinical documentation.
- Experience with record review, data abstraction, auditing, reporting, and data analysis.
- Knowledge of process improvement tools, including PDSA, root cause analysis, process mapping, and performance measurement.
- Ability to facilitate interdisciplinary work, manage priorities, communicate effectively, and influence without direct authority.
- Proficiency with electronic health records, medical terminology, coding concepts, and reporting tools.
Supervisory Responsibilities
- None.
Physical Demands
Exerts up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Involves sitting most of the time, but may involve walking or standing for brief periods of time. The worker is subject to substantial overtime, evening meetings, on-call status, contact with chemicals, contact with infectious fluids, heavy lifting, constant standing, extensive close work, extensive computer work, and encounters with upset/disturbed individuals.
Required Education and Experience
- Minimum of three (3) years of healthcare leadership, quality/process improvement or healthcare as a clinical professional.
- Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma or other accredited healthcare quality improvement certification (within 12 months of hire).
Preferred Education and Experience
- Bachelor's degree in Nursing, Business Administration, Healthcare Administration, or Public Health.
- Current AZ nursing license in good standing.
- Healthcare accreditation, regulatory readiness, clinical quality reporting, documentation, or coding experience.
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.