Medical Quality Improvement Reviewer/CSU/2346/NP

Job Description

Job Description

Location:  Bartow/Lakeland, FL. The Quality Improvement Reviewer is responsible for monitoring, evaluating, and improving the quality of clinical and operational services within Peace River Center's Crisis Stabilization Units (CSUs). This position conducts ongoing audits of medical records, documentation, and unit operations to ensure compliance with agency policies, state and federal regulations, accreditation standards, and best clinical practices. The Quality Improvement Reviewer identifies opportunities for process improvement, assists with corrective action planning, investigates incidents and complaints, monitors regulatory compliance, and collaborates with leadership to promote a culture of quality, patient safety, and continuous performance improvement. This position serves as a resource to clinical and administrative staff, providing education, feedback, and support to enhance documentation accuracy, ensure regulatory compliance, and improve patient outcomes.

General Expectations:

In the performance of their respective tasks and duties, all employees are expected to conform to the following:

1. Adhere to all PRC policies and Code of Conduct standards and always exhibit all PRC's Core Values.
2. Perform quality work within deadlines with or without direct supervision.
3. Interact professionally with other employees, customers, and vendors.
4. Work independently, while understanding the necessity for communicating and coordinating work efforts with other employees and organizations, as required.

Essential Duties/Requirements:

• Ability to arrive/report to work on time and ready to work.
• Ability to abide by principles of EEO compliance and a workplace of dignity and respect.
• Ability to work cooperatively in a group/team setting.
• Ability to show respect and professionally communicate with others.
• Ability to take guidance and direction from supervisors.
• Ability to report to work with clean hygiene.
• Ability to adhere to Company/Program dress code standards.
• Serve as the Quality Improvement liaison for inpatient units; collaborate with cross-functional teams to ensure compliance and continuous improvement.
• Assists in evaluation of data from audits and identification of quality improvement opportunities.
• Participates in Quality Improvement initiatives in assigned roles as delegated.
• Run daily ObservSMART Reports and follow up with management in a timely manner.
• Perform daily chart reviews using standardized audit tool. This will address requirements including, but not limited to:
  • Legal guardianship identified and documented.
• Petitions filed within required timeframes
• Assessments completed within required timeframes, including family involvement (if allowed by client)
• All health needs addressed appropriately and timely.
• Orders documented appropriately (admission, SANDR)
• Required consents/notifications completed and signed.
• Client's home meds are properly documented and stored.
• Medications are prescribed properly and appropriately administered.
• Special orders are documented and executed properly (communication restrictions, diet needs, labs, etc.).
• Treatment plans completed within 24 hours & updated every 5 days.
• Treatment plans are individualized and include family involvement (if allowed by client)
• Progress notes match treatment goals
• Discharge planning is completed properly, including appropriate referrals and family involvement (if allowed by client)
• Clients are provided with appropriate follow-up appointments.
• Random direct observation of unit operations
• Monthly checks of emergency equipment (AED, oxygen, Emergency Drug Kit)
• Conduct Emergency Drills and Training
• Serve as Infection Control liaison for the units.
• Assist with investigation and root cause analysis of reported incidents and complaints, including video reviews of seclusion/restraints ; allegations of abuse, neglect, or exploitation; and medical emergencies.
• Work collaboratively with HR and department leadership to ensure required regulatory and agency training requirements are current.
• Assist with data preparation for Quality Committees.
• Monitor compliance with DCF, AHCA, CMS, Joint Commission (if applicable), and agency standards.
• Track, trend, and analyze quality indicators and prepare reports for leadership.
• Assist departments with developing and implementing corrective action plans following audits or regulatory findings.
• Conduct follow-up reviews to ensure corrective actions have been successfully implemented.
• Participate in preparation for internal and external surveys, audits, and accreditation reviews.
• Maintain confidentiality of protected health information (PHI) in accordance with HIPAA regulations.
• Provide education and feedback to staff regarding documentation deficiencies and regulatory requirements.
• Collaborate with Nursing, Medical, Clinical, and Operations leadership to improve patient care processes.
• Perform other duties as assigned in support of the Quality Improvement Program.

Qualifications:

Education:

Graduate of an accredited school of practical or professional nursing. Current, active, and unrestricted Florida LPN license required; RN license preferred.

Experience:

Minimum of two (2) years of nursing experience, preferably in behavioral health, psychiatric services, quality improvement, utilization review, regulatory compliance, or a closely related healthcare setting.

Certifications:

Current CPR certification is required. Crisis intervention certification required within agency-established timeframes.

Training:

The employee must meet all requirements for Credentialing within the agency. 20 hours of professional enhancement training annually, including all PRC required training. Attends all scheduled work hours, meetings, training, and other center functions.

Knowledge and Skills:

• Excellent written, verbal, and interpersonal communication skills
• Strong knowledge of behavioral health documentation standards and medical record requirements.
• Working knowledge of Florida Baker Act regulations, DCF standards, AHCA regulations, and HIPAA requirements.
• Knowledge of quality improvement principles, performance improvement methodologies, and root cause analysis.
• Ability to interpret policies, regulations, and clinical documentation standards.
• Strong analytical and critical thinking skills.
• Excellent organizational and time management skills with the ability to prioritize multiple assignments.
• Excellent written, verbal, and interpersonal communication skills.
• Proficient in Microsoft Office (Word, Excel, Outlook) and electronic health record systems.
• Ability to maintain strict confidentiality.
• Ability to work independently while fostering positive working relationships with multidisciplinary teams.

Safety Equipment

Universal Precautions

Comply with Occupational Safety and Health Administration (OSHA) rules and regulations.

Life Safety Equipment (fire extinguisher)

Transportation:

Must have reliable transportation.

Machines, Tool, and Equipment Used:

Computer, telephone, fax, copier

Physical Requirements:

• Ability to sit, stand, and walk for extended periods.
• Ability to review electronic and paper medical records.
• Ability to occasionally lift up to 25 pounds.
• Ability to travel between Peace River Center facilities as needed.
• Ability to safely respond to inpatient units during emergencies when required.

Supervisory Relationship(s):

None

Technology Requirement:

As an employee of Peace River Center, if you are not assigned a company-issued phone, you will be required to authorize the use of the Microsoft Authenticator app on your personal mobile device. This is necessary to access our payroll and communication system, Datis, and Microsoft email, as examples. This will ensure secure and efficient communication with the organization.

Work Environment:

The work environment is fast-paced and consists of exposure to physical conditions typical of a normal office environment. The populations cared for will include patients who are confused, delusional, irrational, agitated, or uncooperative. Most of the work is performed while sitting, although the work may require occasional standing or walking and/or the lifting and carrying of small objects. A small amount of travel may be required for meetings, etc., to another PRC location.

EEO Statement

One of the greatest assets of the PRC is the ethnic, cultural, and social diversity of its employees. PRC takes great pride in the diversity and values and respect of all its employees, regardless of race, color, sex, marital status, religion, national origin, ancestry, genetic information, age, disability, gender identification, or sexual orientation.

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