Position Summary: Under the direction of the Director of Quality Management, manages quality projects and data reporting, to include internal and external reporting of quality data (to include all departmental dashboards), and participation and facilitation of quality improvement teams and projects. Position serves as backup coordinator for Joint Commission accreditation activities, to include participation in surveys, annual evaluations, and standards compliance audits.
· Manage and distribute all departmental dashboards within the health system. Score severity of compliance with each indicator, manage dashboard changes, and maintain all appropriate records.
· Manage and distribute all physician quality profiles. Work closely with the Director of Medical Staff Services to maintain content of these profiles, and work with physician leadership on changes and updates to the profiles as needed.
· Participate in core measures data management, including oversight of data entry and management in MIDAS+.
· Statistical analysis of quality data, to include identification of patterns and trends in this data that can be targeted for improvement. Extensive use of Microsoft Excel to generate graphics of the appropriate type/method (based on data being analyzed) is necessary.
· Generation of multiple quality reports, including dashboard summaries, ED & Urgent Care throughput, Cardiology quality reports, and more at the direction of the department Director.
· Manage review and updates of all administrative-level and Process Improvement Department policies in the organization. This includes regular and routine follow-up with all levels of leadership within the organization to coordinate policy review and updates, as needed.
· Serve as backup Joint Commission liaison to the Director of Quality Management and Process Improvement. Duties include survey preparation, internal tracer auditing, report generation and review, responding to standards inquiries within the organization, and participation in survey as a scribe or chaperone. Experience in this area is preferred, but not required.
· Serve as an ISO internal auditor. Training will be provided.
· Perform other duties as requested
· Exceptional computer skills are a MUST. Extensive experience with Microsoft Excel, Word, and PowerPoint is preferred. Candidate must be able to create various types of graphics within Excel using quality data, and present these graphics in a professional and polished manner.
· Strong verbal and written communication skills. Must be able to interact professionally with all levels of staff and leaders within the organization, up to and including co-workers, senior leaders (Vice Presidents) and members of the medical staff.
· Strong interpersonal skills and an ability to work with others effectively, cordially and tactfully.
· Good critical thinking ability, to enable the candidate to think abstractly and make appropriate decisions when managing the workload.
· Detail-oriented candidates will have the strongest consideration. Must be able to turn out error-free work product on a regular and consistent basis.
· Ability to work independently.
· Ability to meet strict deadlines.
· Dependable and trustworthy, with a capability for dealing with sensitive information in a confidential manner at all times.
· Ability to learn new tasks quickly.
· Ability to operate telephones, printers, copier, and fax machine.
· Familiarity with LMH organizational structure is a plus.
· Experience with MIDAS+ is desired.
Licking Memorial Health Systems is an equal opportunity employer and maintains compliance with all state, federal, and local regulations. Licking Memorial Health Systems does not discriminate against applicants because of race, color, religion, sex, sexual orientation, age, ancestry, national origin, veteran status, pregnancy, disability, marital status, or other characteristics protected by law.