JOB SUMMARY CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner.
HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous research centers in the U. S. and Korea including a medical university, and CHAUM (a premier anti-aging life center). MAJOR RESPONSIBILITIES/ESSENTIAL FUNCTIONS Coordinator for the facility’s Core measure, other clinical and operational process improvement initiatives as assigned.
Performs detailed, concentrated clinical and regulatory review with limited supervision. Identifies, at the earliest opportunity, any Core Measure regulatory changes that may impact the organization and make recommendations of how compliance can be achieved. Uses problem-solving skills to proactively take action on individual cases not meeting measure requirements.
Serves as a clinical quality resource for nursing and other clinical personnel, physicians, and other ancillary departments. Prepares reports for various stakeholders as assigned. Able to tailor data and reports to intended audience with minimal supervision.
Communicates relevant information to appropriate department managers, provides follow-up to ensure new standards are being met. Tracks elements of action plans to ensure timely monitoring and prepares reports as requested. Communicates and interacts with physicians professionally and effectively.
Screens medical records utilizing pre-established, pre-approved criteria as part of the Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation when applicable, as assigned. Ensures the integrity of data being reported and utilized. Designs and develops dashboards, presentations, educational materials relevant to the clinical audience.
Demonstrates clinical and professional judgment in case referral determination. Maintains an accurate knowledge of clinical quality measures and the outcomes to be achieved. Provides assistance and support for patient care tracers as assigned.
Exhibits flexibility to learn new areas, expanding clinical, professional, regulatory and technical knowledge and skills. Maintains confidentiality of information at all times. Coordinates and facilitates Medical Staff Quality Review which includes case review, physician and physician specific tracking, trending and reporting of case review, as well as mortality and complication reviews.
Abstraction and analysis mandatory outcome measures, as necessary. Assists the Quality Department in achieving identified quality outcomes. Collects, analyze, and inputs clinical and operational data into various databases to support process improvement.
Works collaboratively with teams to set goals that are realistic and meaningful and result in quantifiable improvement. Ensures an effective data collection and processing system by reviewing and analyzing data input, processing and data output activities. Ensures accuracy and consistency in data collection by the Quality Management staff.
Performs audits to evaluate the quality and timelines of medical records completion to ensure optimum care delivery. Assists with special projects, committees provides meeting support, e.g., ensure meetings are scheduled and designated individuals invited, prepares agendas, records/distributes/archives minutes, ensure follow-up on action items when needed. Maintains accurate minutes and communication to various stakeholders within the organization.
Produces reports, completes assigned projects timely with little follow up. Communicates and interacts with physicians, administration, and peer groups, appropriately, professionally and effectively. Provides assistance and support for patient care tracers as directed.
Exhibits flexibility to learn new areas, expanding professional, regulatory and technical knowledge and skills. Maintains confidentiality of information. All other duties as assigned JOB QUALIFICATIONS Minimum Education LVN, RN, NP, PharmD, MD/DO, RT, or CLS Preferred Education Bachelor’s degree in nursing or related field, or equivalent experience.
Minimum Work Experience and Qualifications Previous success in developing and implementing new practices and controls (with specific improvements). A working knowledge of hospital policies and procedures. Analytical and statistical skills to design internal audits.
Ability to present pertinent fata and recommendations clearly and concisely in a manner appropriate to end-user audiences. Excellent computer knowledge; experience with Excel, Access, Windows, word processing, spreadsheets, graphing, charts, various software, etc. Ability to communicate effectively verbally and in writing.
Must be able to work in a union environment. Preferred Work Experience and Qualifications CPHQ certification Required Licensure, Certification, Registration or Designation If RN licensure designation, current and active California Nursing License required Current Los Angeles County Fire Card (required within 30 days of hire) Assault Response Competency (ARC) (required within 30 days of hire) Status: Full Time Exempt
Days Hours: 8hrs (Exempt) Weekly/Bi-Weekly: 40hrs/80hrs (Exempt) FTE: 1.0