Clinical Quality Director (RN)
Company: Pinehurst Surgical Clinic PA
Posted on: November 25, 2022
SUMMARY: The Clinical Quality Director assumes leadership
responsibility for the assessment, development and implementation
of clinically effective systems within the continuum of care. Works
in partnership with the operations director and department managers
to develop strategies that create and sustain a culture of clinical
excellence. Ensures adherence to established clinical policies,
protocols, regulations, and standards. Applies knowledge of nursing
and clinical data management to assist in the design, development,
and ongoing modification of computerized health care systems.
- Nursing license required; RN preferred
- Not less than 3 years clinical experience
- BLS certified required; ACLS preferred
- Extensive experience with EMR utilization and
- Experience in ensuring compliance with clinical regulations and
- Quality measurement, reporting and data analysis
- Extensive experience with Meaningful Use, PQRS and other
quality reporting to help the organization be successful in MIPS or
other quality reporting programs
- Training and presentation experience
- Experience in deploying clinical quality improvement
- Detail oriented
- Highly skilled in Excel PERSONAL CHARACTERISTICS:
- Excellent telephone skills and etiquette
- Maintains confidentiality & complies with HIPAA
- Exemplary customer service skills
- Able to work both independently and in a team environment
- Takes initiative
- Holds and maintains high standards
- Ability to relate sensitively to patients needs in stressful
- Well-organized POSITION REQUIREMENTS: EMR Support
- Lead quality measurement and reporting program focused on
improving the quality and value of the services offered to our
- Optimize MIPS, ACO and other quality metric utilization through
researching CMS requirements, rewards, and consequences. Lead
organizational communication of the information to managers,
employees and providers after the information and organizational
plan is approved by the OD and IT Director.
- Provide leadership and guidance to managers, and assist
departments with attestation/reporting for all providers in every
quality program that PSC participates in.
- Responds to any quality reporting audits with the assistance of
the OD and the IT Director.
- Support EMR based workflow analysis to maintain standards and
process integrity while optimizing efficiency and
- Establish clinical reporting requirements with an emphasis on
streamlined, standard reporting to minimize special requests.
- Collaborates with IT to meet CMS attestation/reporting for all
quality reporting programs. Quality Committee
- Chair monthly Clinical Excellence Committee: prepares agenda,
materials and minutes.
- Monitor satisfactory completion of clinical projects and tasks
with the department managers and lead staff.
- Support monthly Quality Operations Committee as needed. Help OD
with QOC packet materials.
- Facilitate and leads the MIPS portion of the Clinical Quality
Meeting. Quality Operations
- Institute clinical quality monitoring and measurement systems
by benchmarking Pinehurst Surgical services and work processes to
similar organizations to identify best practices for the purpose of
continuous quality improvement.
- Serves as the clinical consultant for program/service
development, other projects, policy, procedures and
- Annually review and modify as needed and required by our AAAHC
accreditation patient care policies and procedures. Submit updated
or new policies to OD for approval prior to submission to the QOC
and medical director.
- Collaborate with Operations Director in the development and
execution of improvement plans to prevent sentinel events and
incidents that impact clinical quality including patient complaints
concerning clinical standards or outcomes.
- Ensure compliance with all applicable AAAHC standards. Lead
AAAHC survey activities for the entire organization.
- Support operational process improvement through management
reporting and analysis; of charting deficiencies and other reports
on a monthly basis. Must understand how to proficiently use Excel
spread sheets, use formulas and create pivot tables.
- Ensure compliance with Patient Care, Infection Control, Quality
and OSHA policies and procedures.
- Develop curriculum and training to promote clinical excellence
among clinical staff.
- Respond to emergency Code situations. Conducts follow-up
assessment on codes to pursue continual improvement. General
- Facilitate Quality Meetings
- Manage the annual quality budget
- Project planning and execution
- Implement operational improvements
- Pursuit personal professional development
- Availability, during and outside of work hours, including while
on PTO, is expected, within reason, for the continuation of
efficient clinic operations PI196790232
Keywords: Pinehurst Surgical Clinic PA, Fayetteville , Clinical Quality Director (RN), Executive , Pinehurst, North Carolina
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