Mgr-RHPA Quality

• About the Position

Under the direction of the Director of Quality, the Manager is responsible for the overall management of quality review and improvement processes for the Hospital and RPA and other designated areas.

Essential Duties and Responsibilities

• Assists Quality Director with daily operations of the department.
• Serves on hospital committees as invited and as assigned by the Director of Quality.
• Timely and accurate data collection and submission of required quality measures to CMS, ACO, ACC, STS & other registries which the hospital & RHPA has chosen to participate in compliance with hospital quality programs.
• Continues education and remains familiar and knowledgeable of the various CMS rules and regulations regarding quality programs.
• Assists the Quality Director with performance excellence projects, as defined in organizational strategic framework.
• Oversight and coordination of annual clinical contract review & QAPI.
• Familiar with requirements for the IQR (Inpatient Quality Reporting), OQR (Outpatient Quality Reporting), IPFQR (Inpatient Psychiatric Facility Quality Reporting and Promoting Interoperability programs of CMS.
• Leads quality department continuous DNV survey readiness.
• Leads and coordinates completion of the Leapfrog Hospital Safety Survey, Anthem QHIP survey, AHRQ’s Culture of Safety Survey and other system-wide quality surveys the organization chooses to participate in.
• Manages quality review for physicians & Providers belonging to RH & RHPA in accordance with the FPPE & OPPE Policy.
• Reviews MIDAS Patient Satisfaction Issues for quality of care concerns and participates in the hospital grievance process. Provides follow up with customers as needed.
• Serves as a quality representative on various committees or Medical Staff meetings as assigned by the Quality Director and prepares standard reports for the committee.
• Responsible for maintenance of employee schedules and timecards for direct reports.
• Ensures timecards are completed timely on payroll Monday.
• Sets and communicates clear performance expectations of team members and monitors by direct observation.

Education and Experience

• Minimum of Bachelor’s Degree in health related field or Bachelor’s Degree in other field
• Experience as leader in the Quality is preferred.

Licensure and Certification

RN, LPN, RHIA, RHIT, CPHQ, CPHRM or other healthcare related credential helpful.