New Hanover Regional Medical Center Mgr Quality & Outcomes-PMH - Pender Memorial Hospital in Wilmington, North Carolina

Mgr Quality & Outcomes-PMH - Pender Memorial Hospital

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Pender Memorial Hospital





Job Details

This position is located at Pender Memorial Hospital in Burgaw, NC. Current NHRMC employees applying to this position should complete a Pender Memorial Hospital external application by clicking below the job description on Click Here to Apply Online. This position would not be considered an internal transfer for an NHRMC employee. This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance. All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center. JOB SUMMARY: The Manager of Quality and Outcomes is a Registered Nurse reporting to the CNE to achieve improvements in patient outcomes, operational performance, utilization management and variations in practice. This is a multifaceted role, incorporating expertise in clinical practice, utilization review, data analysis, research, risk management and performance improvement methodologies in order to achieve measurable improvements in the five pillars: service, people, quality, finance and growth. The Manager of Quality and Outcomes is responsible for the Social Workers, Social Work Administrative Coordinator, Community Liaison (SNF/Swing) and Transport Specialist. The Manager of Quality and Outcomes is self-directed and acts as an effective leader, catalyst for change, and role model for quality nursing practice. PRIMARY JOB DUTIES: 1. Effectively facilitates assigned clinical outcome initiatives in collaboration with medical and hospital staff to redesign operations and clinical practice in support of the hospital's strategic initiatives, goals and objectives (identifying opportunities for improved outcomes, reduced cost, improved LOS, and best practice utilization of resources). 2. Coordinates the development of annual quality improvement plan. 3. Directs the organization-wide program for performance measurement, analysis, and improvement including data use, benchmarking and performance improvement teams. 4. Utilizes clinical data bases and national benchmarks to identify opportunities for improved outcomes, reduced cost, improved LOS and best practice utilization of resources. 5. Coordinates activities of peer review process including case review against defined performance measures for referral through the peer review process. 6. Leads the effort to gather OPPE/FPPE for the Medical Staff. 7. Assists with facility response to significant and/or sentinel events and assists with timely evaluation and completion of root cause analysis and action plan. 8. Coordinates data abstraction requirements to support timely completion and validation of all public reporting projects for HQI, Core Measures, and CMS. 9. Coordinates activities necessary to facilitate success with organizational priorities such as Joint Commission, CMS and other strategic initiatives. 10. Serves as expert resource and consultant related to control of utilization of outpatient in bed and inpatient hospital services that include certification of medical necessity based on plan of care and utilization review. Applies InterQual guidelines criteria to evaluate denied claims for appealability. 11. Coordinates with Manager of Patient Financial Services all aspects of denial management. Initiates appeals on all appropriate cases of the clinical denials and tracks avoidable days and dollars recovered. 12. Liaison to Health Information Management and Patient Financial Services staff regarding medical record documentation for level of care, coding and correct billing status, including release of bills when suppressed for pending appeal. 13. Oversees the hospital notice of non-coverage process which includes responsibility for notification of all appropriate parties when letters are issued. 14. Stays abreast of changes in regulatory requirements for utilization review. 15. Maintains contact with primary external payers in order to promote effective utilization review processes and address process improvement issues. 16. Demonstrates proficiency in all utilization management software and hospital information systems used to obtain clinical information on patients. 17. Demonstrates Standards of Performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence. 18. Perform other duties as assigned. ESSENTIAL JOB SPECIFICATIONS: Education: Bachelors degree in Nursing required; Master's degree in nursing, business or related field preferred. Licensure/Certification: RN required; CPHQ certification and Utilization Management certification preferred Experience: Minimum of 5 years experience as RN with 3 years experience in quality, peer review, regulatory compliance, etc. Other – Hours of Work: Flexible 8 hour shifts, Monday through Friday to meet needs of hospital.