Stroke & Chest Pain Accreditation Specialist

If you're looking for a place to call home and grow, Three Crosses Regional Hospital is looking for you! We are looking for Quality Value Based Purchasing/Cardiac Accreditation Specialist that is committed to clinical excellence and building a patient-centered culture.

Three Crosses Regional Hospital is an advanced independent healthcare organization led by a local team of professionals dedicated to high quality patient care and being the first choice of patients and providers in the communities we serve.

We are dedicated to hiring team members that will adapt to our culture, pride themselves in professionalism, integrity, transparency, two-way communication, and ensuring the safety and well-being of our patients and staff.

The Quality Value Based Purchasing/Accreditation Specialist is a registered nurse who is independently accountable for the effective management, development and compliance to quality programs. They will be responsible for data collection, care standards and regulatory reporting related to VBP and accreditation activities. This position will ensure adherence to applicable federal and state guidelines and accreditation standards. The Quality Value Based Purchasing/Accreditation Specialist will also assist the Director of Quality & Compliance with duties to the overall department. This role is key by overseeing and reviewing data collection, analysis/interpretation, trend identification and process improvement implementation for the VBP program and accreditation activities. They will abstract and compile medical information from patients' records as a service to hospital and various agencies associated with patient care and outcomes.

The incumbent will carry-out her/his duties by adhering to the highest standards of ethical and moral conduct, acts in the best interest of Three Crosses Regional Hospital, and fully supports the mission, vision, and values of Three Crosses Regional Hospital. The incumbent will have knowledge of health care systems, and have demonstrated ability to interact, relate to, work with, and support the activities of a diverse workforce.

Primary Responsibilities

• Assists Quality Improvement (QI) director to plan, design, implement, and maintain a comprehensive continuous quality improvement (CQI) program related to VBP and accreditation activities.
• Assist with accurate data collection and analysis to support national registries, process improvement and quality initiatives.
• Collaborates with staff, managers, education department on department quality improvement initiatives relating to VBP and accreditation activities.
• Coordinates the delivery and documentation of safe quality patient care that promotes the professional care delivery model. This includes, but is not limited to diverse and inclusive interdisciplinary communication methods (interdisciplinary rounds, case review, etc); completion of timely documentation and promotion of a respectful, inclusive clinical environment.
• Participates and supports performance improvement activities inclusive of all stakeholders, research and research utilization to promote safe, quality patient care including initiating and/or leading such activities as well as, promoting an inter/intra-disciplinary process and actively supports/participates in shared governance at all levels in the system.
• Assists in educating new staff, including physicians, about VBP and required accreditation standards.
• Monitors clinical practice efforts to ensure compliance with VBP and required accreditation standards.
• Completes detailed medical records and maintains oversight of medical record and other documentation to ensure quality care.
• Helps to prepare and analyze reports for multiple committees, departments and meetings.
• Conducting or assisting with regulatory and quality training sessions.
• Determining data-driven solutions and implementing quality improvement plans for VBP and accreditation activities.
• Responsible for maintaining quality management documents, case files and correspondence in an organized, confidential, and secure manner.
• Abstracts, reviews and prepares medical record information for audits by multiple departments.
• Submission of data to reporting agencies i.e., CMS, AO, NMDOH.
• Works collaboratively with Quality Data Analyst and Leadership using healthcare data to achieve optimal outcomes for patients and organization.
• Facilitates ongoing feedback and effectively communicates & coordinates with internal customers to identify trends.
• Attends meetings as needed.
• Other duties as assigned.

Education and Experience

• Required: Associate degree in healthcare, bachelor's degree preferred.
• Required: Current New Mexico license: RN

"We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law".