Quality Measure Coordinator

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:
$94,556.80 - $124,176.00

Scheduled Weekly Hours:
40

Position Overview

Improves public reported data (CMS, NJDOH, Leapfrog) by ensuring its accuracy and integrity through data abstraction, analysis, and reporting. Provides close collaboration with clinical and administrative teams to fully understand the data elements reported and implement quality improvement projects to improve quality outcomes. Evaluates adherence to compliance standards and maintains documentation for regulatory auditing. Collaborates with internal departments to ensure data integrity and documentation accuracy. Develops dashboards to track metrics.
MINIMUM REQUIREMENTS

Education:Bachelor's degree. Master's degree preferred. Related certification preferred.

Experience:Three years of related healthcare experience required. Five years experience in a healthcare environment preferred. Experience with data analysis and management of clinical databases preferred.

Other Credentials:Registered Nurse - NJ or Registered Nurse - NLC multi-state

Knowledge and Skills:Possesses knowledge of PI tool, analytics and data management. Excellent coaching, organizational, interpersonal, verbal and written communication skills. Ability to effectively manage multiple projects simultaneously and ability to respond quickly in a fast-paced environment.

Special Training:Intermediate to advanced computer skills.

Mental, Behavioral and Emotional Abilities:

Usual Work Day:8 Hours
Reporting Relationships

Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.
ESSENTIAL FUNCTIONS

• Maintains current knowledge of regulatory measures, applicable clinical practice guidelines, and their impact on quality outcomes and pubic reporting.
• Maintains a comprehensive "inventory" of publicly reported measures/program, including deadlines, measure specification and keeps current on program updates/changes (Measure specifications, program changes, Proposed and Final Rules.
• Educates providers and team members on their impact on reported measures to improve compliance and outcomes.
• Identifies and manages the escalation and resolution of activity/process issues that impact public reporting.
• Serves as a resource for all activity/process related quality reporting questions and inquiries by the system.
• Coordinates, monitors, validates and reports performance/compliance status with regulatory measure objectives throughout the system.
• Analyzes, validates, and reviews reports to evaluate adherence to compliance standards and reporting.
• Partners with department leaders, providers and staff to review individual performance related to regulatory measure metrics.
• Coordinates and maintains supportive documentation to demonstrate evidence of compliance with regulatory requirements.
• Collaborates with the IT department and ancillaries to ensure processes for capturing data from electronic health record (EHR) supports attestation of the regulatory measure initiatives.
• Develops and analyzes system-generated reports on EHR system data and eCQMs.
• Effectively coordinates with IT staff to improve efficiencies and usability with the ER application.
• Collaborates with clinical information staff to ensure current and future stages of MU are built to support end user quality metrics.
• Collaborates with CDI and Coding staff to ensure accuracy of documentation and coding, and the impact on reported metrics.
• Coordinates and maintains supportive documentation for regulatory measure audit files to demonstrate evidence of compliance with regulatory requirements. Coordinates and submits audit responses.
• Works with quality management, infection prevention and patient experience to develop and monitor plans for system performance improvement functions impacting public reporting.
• Coordinates data reporting, and performs analysis to support performance improvement and department compliance.
• Collaborates with Public Relations Department of dissemination and interpretation of publicly reported measure.
• Provides ongoing education to end-users on regulatory measure initiatives to align outcomes and performance metrics with regulatory measure requirements. Assists with assessment of end-user workflows/processes to ensure compliance with regulatory measures.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Sitting , Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion , Talk or Hear

Occasional physical demands include: Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks Include the following: N/A

This position is eligible for the following benefits:

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits - Long Term Disability (LTD)
• Disability Benefits - Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level.


The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.