NI-Coordinator, Quality Improvement

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

6/17/2021

Entity:

Illinois

Job Code:

NI-2330CL

Job Title:

NI-Coordinator, Quality Improvement

Exemption Status:

Exempt

JOB SUMMARY

Coordinates and integrates the development of quality assurance and improvement, regulatory compliance, risk management and service excellence for the UW Health Medical Group.

MAJOR RESPONSIBILITIES

•

Coordinates and integrates programs and processes that achieve regulatory compliance and quality improvement, manages risk, and promotes service excellence and supports the organization’s philosophies. Utilizes CQI principals to identify opportunities for improvement concerning regulatory compliance, clinical and service excellence.

•

Educate managers, providers, and staff regarding regulatory compliance, risk management, patient safety, and quality improvement activities.

•

Make recommendations based on interpretation of regulatory standards including JCAHO, HIPPA, NCQA, (HEDIS), IDPH, MIPS, etc.

•

Engages in benchmarking activities which compare clinic performance to best demonstrated practices, professional standards and internally developed targets.

•

Coordinates audits, studies and data collection, analysis and submission to SAMG and SAHS committees.

•

Prepares and presents information on regulatory compliance and quality improvement activities to various committees including those that oversee regulatory compliance, patient safety, risk management, and quality improvement activities.

•

Coordinates SAMG committees that oversee regulatory compliance in the clinics.

•

Serves as a liaison with other UW Health departments and external organizations as appropriate.

•

Writes, updates, and reviews SAMG policies and procedures as scheduled to ensure regulatory compliance or to reflect changes in operations.

•

Conducts audits of the medical record to monitor for regulatory compliance, risk management, and quality assurance.

•

Educates SAMG clinic nursing staff by developing tools for education, including standard work, competencies, and annual skills.

ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS.

X

Non-Clinical

JOB REQUIREMENTS

Bachelor of Science degree in nursing (BSN).

Required

3 years

experience in quality assessment / improvement, clinical pathways or CQI in a health care setting.

Required

•

Demonstrated project planning and project management skills, excellent organizational skills, ability to prioritize and organize competing tasks, good problem solving skills.

•

Knowledge of quality improvement study design, basic statistical analysis and report writing.

•

Strong attention to detail.

•

Ability to effectively interact and communicate with all levels of staff and physicians within the organization and community.

•

Successful completion of annual job specific competencies and skill verification tools required.

•

Familiarity with JCAHO requirements and CQI philosophy essential.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Standing

X

Walking

X

Climbing

X

Bending

X

Crouching

X

Pushing / Pulling

X

Carry

X

Fine Hand / Eye Coordination

X

Color Discrimination

X

Hearing Ability

X

Lifting / Lowering 1 -15 lbs.

X

15 - 30 lbs.

X

30 - 50 lbs.

X

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Concentration on Detail

X

Attention Span of 1 + Hours on a Task

X

Ability to Remember Multiple Tasks

X

Oral Communication

X

Written Communication

X

Exposure to Blood and Body Fluids

X

Exposure to Toxins, Cytotoxins, Poisons

X

Exposure to Extreme Heat, Cold, Temp Fluctuations

X

Exposure to Hazardous Chemicals

X

Exposure to Radiation

X

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.