Provides comprehensive review of patient care issues. Assists with the implementation of the hospital and medical staff performance improvement program. Collects and organizes data to support hospital quality initiatives. Serves as member of appropriate committees/teams.
Essential Functions
- Performs accurate and thorough chart audits for care issues, complaints, and abstractions (HSAG, IHI, Qnet).
- Conducts investigations related to patient complaints and incident reports in Quantros.
- Participates in implementation of evidence-based practices for the facility.
- Performs data collection for trending physician activity and quarterly reports.
- Monitors feedback reports (i.e. Patient Satisfaction vendor to create scorecards/dashboards demonstrating the perceived quality of care and satisfaction).
- Coordinates Peer Review process.
- Communicates information and follow-up work; assists managers within the service lines.
- Facilitates and participates in designated meetings; types agenda and minutes.
- Performs all functions according to established policies, regulatory and accreditation requirements, and professional service standards.
Other Duties
- Posts the PI bulletin board.
- Implements new processes and educates staff hospital wide.
- Conducts various surveys, CMS and HSAG chart reviews, monthly physician department meetings.
- Participates in departmental and association wide informational meetings and in services, including staff meetings, association wide forums, and seminars.
- Reviews department and association wide policies and procedures annually. Develops and maintains new policies and procedures as needed.
Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.
Abilities
- Must be able to read, write, understand, and speak English.
- This position requires operational knowledge of all equipment in the Performance Improvement department, including: fax, printers, copy machine, phone systems, and commonly used computer programs in the hospital.
- Service orientated
- Excellent customer service
- Organizational skills
- Multitasking skills
- Professional interpersonal skills
- Time management skills
- Telephone etiquette.
Supervisory Responsibilities
None.
Work Environment
At Summit Healthcare, our mission statement is that we are trusted to provide exceptional, compassionate care close to home. Our vision is to be the healthcare system of choice.
To uphold our mission and vision statements, we expect all employees to practice SHINE Behavioral standards:
- Always SHINE – show respect and be kind.
- Always work together – we are on the same team.
- Always serve others – no job is beneath you.
- Always maintain high standards of quality and safety – best practice every time.
- Always communicate clearly – be compassionate.
- Always practice integrity – maintain confidentiality.
- Always be accountable – take responsibility.
- Always empower – create an environment of success.
- Always excel – don’t settle for mediocrity.
- Always promote wellness – make choices for a healthy lifestyle.
Physical Demands
Exerts up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and/or a negligible amount of force constantly to move objects. Physical demands are in excess of those of Sedentary work. Light work usually requires walking or standing to a significant degree. Worker is exposed to extensive computer work.
Required Education and Experience
- BLS CPR AED within 30 days of hire
- Current AZ RN license
- 5 years of experience as an RN
- Certification in Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma, or another accredited healthcare quality improvement certification (within 18 months of hire).
Preferred Education and Experience
- Master’s Degree
- Advanced Practice Nurse Certificate
OSHA Exposure Category:
Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues and are not a condition of employment.
Related Jobs

RN Utilization Review II-Behavioral Health-FT/Days

Clinical Care Reviewer II- Must have Post Acute Exp-RN-MSL

RN Quality Review Manager- Registered Nurse

RN Peer Review Coordinator

