The Quality Coordinator RN role will perform quality process reviews of charts, audit data and investigate any irregularities. In addition, this role will provide analysis of data accreditation for compliance purposes.

Job Summary:

• Provide leadership to the organization in coordination with all things related to regulatory standards and elements of performance for CMS, IDPH, TJC and any other regulatory agencies.
• Will co-lead on-site hospital surveys with TJC and in collaboration with other owners for Disease State Certification site surveys (stroke and diabetes).
• Provide leadership in collecting accurate data, establishing systems for tracking/trending of data, analysis of accreditation data. Serves as expert in regulatory compliance.
• Serve as expert in presentation of regulatory findings and changes in standards.
• Provide leadership in Evidence Based Practice related to accreditation, helps to identify needed processes for concurrent monitoring of compliance and collaboratively works with chapter owners on oversight of current processes to achieve compliance.
• Provide leadership and presentation of findings with Mock Surveys and ongoing departmental findings for medical staff meetings, and quality meetings and hospital department reports that include graphs, charts, scorecards, statistical presentation and power point. Co-lead the accreditation readiness committee meetings (ARRC).
• Function as mentor or leader in multidisciplinary team improvements, understanding team building, customer satisfaction, organizational skills to support the teams such meeting deadlines and expertise in data management including accomplishment of outcomes
• Function as expert in electronic and software programs such as Epic, Word, Excel and Power Point. Preferred knowledge and expertise of tracer software
• Able to perform electronic chart reviews as needed for Disease State Certification Measures
• Serves as a role model whose beliefs, attitudes and actions support organizational leadership and goals.
• Demonstrates proficient leadership skills at the department level.
• Demonstrates accountability for own professional practice, including progress toward achievement of annual goals