Accreditation and Regulatory Clinical Improvement Specialist

A&R CLINICAL PERFORMANCE IMPROVEMENT SPECIALIST Duties Under the supervision of the Manager of the Accreditation and Regulatory Department, provides clinical, technical, and analytical support and evaluation of operational processes and statistical data necessary to support adherence to applicable accreditation and regulatory agency standards. JOB KNOWLEDGE: • Excellent knowledge of structured problem solving and team facilitation skills and strategies. • Excellent Excel and Word processing skills. • Skilled at data analysis and interpretation. • Ability to learn data management systems to enhance ability to illustrate and interpret statistical data in a meaningful way. • Knowledgeable in statistical processes. • Familiar with medical terminology and DRG’s, ICD 10 codes and CPT codes. • Knowledgeable of acute care hospital applicable laws, regulations and standards, Skills • Assists the Manager with all regulatory and accreditation activities as assigned. • Conducts ongoing patient tracers to assure standards readiness, Assures data is entered in the Compliance software timely. Submits accurate reports to department leaders as required. • Completes reports for Accreditation and Regulatory Committee as requested. • Participates on PI teams as requested. • Policy/Process participates in policies/procedure development as requested based on analysis of tracer data. • Staff Resource/Educator - Functions as a resource/educator for Accreditation and Regulatory processes and provides ongoing training to leaders and staff. - Assists Department leaders with development of intra and interdepartmental processes to improve the efficiency, effectiveness, and safety of patient care and departmental operations to assure meeting applicable standards. - Attends facility committees as assigned by the Department Manager. • Manages time to ensure that workload for multiple projects is completed within the required time frame. • Demonstrates motivation and ambition on the job, adapts to and supports change, independently seeks unassigned work without impacting quality, is flexible, thinks along original lines, questions old methods and offers suggestions for improvement of procedures. • Assists organizational staff with development and implementation of process improvements as requested. • Assists leadership with creation / management of department or project specific data needs via regulatory software program to assist in defining dashboards / scorecards. • Ensures improvement team targets are consistently met or exceeded within the required time frame. • Participates in Safety Alerts Gap analysis and manages follow up on Action Plans. • Complies with all applicable health system policies and procedures. • Performs other duties as assigned. Education Bachelor’s degree required, preferably in a healthcare discipline. Licensure: Current California Registered Nurse (RN) license. . Certification in the department specialty preferred (CPHQ, CPPS, and HACP). Experience: At least 3 years direct experience in an acute hospital setting with clinical healthcare providers across a healthcare organization required. Previous experience with regulatory / accrediting agencies and performing tracers is highly preferred.