Job Description

The Coordinator Performance Improvement/Risk Management is responsible for assisting the AVP Hospital Performance Improvement/Risk Management in overseeing, planning, and implementing new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of all regulatory program review and accreditation surveys and federal/state QI compliance activities.

• Utilizes performance improvement model (Plan-Do-Study-Act) to improve patient outcomes
• Works with standing committees and department heads to accomplish objectives of Performance Improvement programs
• Participates in Hospital Acquired Conditions reduction activities, including surveillance and workgroups
• Review and analyze occurrences to determine the need for referrals to appropriate individuals for review.
• Participates in Risk Management activities including but not limited to internal and external RCAs as needed.
• Conducts and participates in regulatory program review and accreditation survey preparation and Mock Surveyors to constant state of readiness.
• Responsible for preparing and conducting Survey Readiness meetings as needed
• Manages all on-site regulatory and accreditation visits,
• Coordinates all activities surrounding the application and on-site readiness for Joint Commission, OASAS, DOH, etc. Certifications.
• Coordinates the formulation of a comprehensive Plan of Correction (POC) with relevant staff/leaders
• Ensures the monitoring of POCs and providing compliance feedback to stakeholders.

Requirements

• NYS RN license required. Bachelor’s degree required; master’s degree preferred.
• 1-3 years of related experience required.
• Strong verbal and written communication skills.
• Proficient in Microsoft Office Suite
• Knowledge of medical terminology, clinical concepts
• Knowledge of Hospital Regulatory process a plus

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