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Primary Responsibilities for Quality Hospital Accreditation:

Lead assigned accreditation readiness activities for internal mock-surveys, and required accreditation activities. Responsible to ensure a continuous readiness in collaboration with healthcare quality colleagues and management, within assigned area of responsibility, and in close collaboration with Director, Quality Management for Hospital Accreditation. Manage the establishment, compliance, and policy and procedure evaluation of the assigned accreditation functions. Conduct reviews of the effectiveness of the Quality Management Plan and related Policies and Procedures, and reviews and revises the Plan, its Program Goals and Objectives, and all related Policies and Procedures as necessary. Participate in the development of, and continuously monitor, an internal reporting structure for quality management and related activities under the direction of senior management. Ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process. Assist committees and departments with PI planning, organization, design of monitoring systems, implementation of study topics and follow-up activity, as necessary. Coordinates timely reporting through the defined, formal reporting structure. Educate faculty, administration and staff in the identification of opportunities for improvement and methods of collecting, analyzing, and reporting of findings and improvement strategies. Collaborate with Risk Management, Regulatory Compliance, Healthcare Quality, and Environment of Care Safety Officer in the identification of opportunities for improvement in the areas of clinical quality and patient safety. Manage the timely submission of patient care data for patient satisfaction and TJC. Analyzes findings and implements appropriate interventions to demonstrate improvements in quality outcomes. Ensure accuracy and validation of unit's work product and submissions, ensure deadlines are met, and provide effective coaching and training to collaborators in order to successfully meet established standards of excellence and metrics. Ensure communication and training of new standards and/or regulations to identified stakeholders. Prepare and/or present surveys, reports, and presentations. Lead and ensure compliance for various regulatory requirements. Ensure regulatory agencies are contacted to proactively verify and clarify expectations, as directed by Manager. Work closely with senior management in the development, attainment, and evaluation of metrics /outcomes, and make/ implement recommendations. Work closely with the Quality Management leadership team. Maintain knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals and hospital-based clinics, including but not limited to TJC, CMS, AHCA, Commission on Cancer, and professional nursing standards. Provide support and expertise to perform general functions for the department as requested, on an individual basis or as a team member, e.g., clinical database coordination, team/task force development and facilitation, maintenance of policies and procedures staff education, committee support, continuous accreditation preparedness, quality assurance, data collection and validation, chart review, medical staff peer review and credentialing, and OPPE and FPPE.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS

Education:

Minimum Bachelor's Degree in Nursing, Health Science, Public Health, Health Informatics or a related health care field.

Certification and Licensing:

Minimum State of Florida Practical Nurse (LPN) or Registered Nurse (RN); or ability to obtain a Florida licensure by endorsement in first six months of position start date. Clinical licensure must be kept clear and active for duration of employment.

Basic Life Support (BLS)

Experience:

Minimum of 4 years' experience (comprised of at least 2 years clinical nurse work experience in a clinical or healthcare environment AND at least 2 years direct experience managing clinical quality outcomes involving accreditation and/or quality assurance activities, inclusive of a service lines or a disease specific group).

Proficiency with Microsoft Office Suite programs, Excel, PowerPoint, Word. Working knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals and hospital-based clinics, including but not limited to TJC, CMS, AHCA, Commission on Cancer, and professional nursing standards.

Preference given to any combination of the following experiences:

• Coursework, continuing education completion of quality and patient safety, clinical informatics, patient centered outcomes, quality improvement, and related topics.
• Acute care experience, in clinical specialty, within the last two years.
• National Certification in area of clinical specialty.
• Familiar with aspects of care, standards of care metrics for accreditation and maintenance.
• Experience with EpicCare Ambulatory Core EMR (EpicCare Ambulatory, Care Everywhere, MyChart, Workbench)
• Previous working experience with any of the following programs preferred: Sequel, ProDiver, Care Discovery, Tableau, NetAccess, Cerner, Sovera and/or Vizio
• Experience with spreadsheets and database software.
• Evidence of ability to draw on knowledge from the following areas: Measurement of patient needs and nursing workload, continuous process improvement processes, performance improvement, service excellence, systems for patient safety, healthcare quality.
• Knowledge of the principles and practices of value-based care, including familiarity with barriers to high-value care.
• Knowledge of the principals and practices of value-based decision-making, health care payment / reimbursement, and delivery models.

Knowledge, Skills and Behaviors:

• Commitment to University Values: Diversity, Integrity, Responsibility, Excellence, Compassion, Creativity, Teamwork.
• Excellent technical skills: Demonstrated competency in computer applications, inclusive of the ability to learn new applications and programs; excellent typing skills.
• Professionalism: Ability to incorporate national professional organization as well as business unit and health system's goals to improve patient safety and quality outcomes.
• Excellent interpersonal skills: Ability promote and sustain outstanding interpersonal and customer service skills (verbal and written) while accepting responsibility to ensure all working relationships are respectful and professional.
• Excellent critical thinking skills: Ability to consistently apply independent and critical thinking skills to solve problems and escalate problems.
• Ability to be self-directed while successfully managing the prioritization and execution of multiple deadline-driven projects simultaneously.
• Excellent attention to detail: Demonstrated ability to accurately review, screen and enter data.
• Excellent communication and presentation skills: Ability to clearly, effectively, and respectfully communicate questions, ideas, and solutions verbally and in writing to a broad spectrum of specialized skill and clinical experience.
• Ability to conform to shifting priorities, demands, and timelines through analytical and problem solving capabilities
• Ability to ensure consistent and accurate adherence to established workflows and processes.
• Required ability to sustain mature judgement and maintain strict confidential information and patient confidentiality as mandated by HIPAA, and University policies, respect the rights and privacy of others at all times.
• Required to maintain current knowledge and practice in compliance with standards established by external regulatory agencies that impact job performance and deliverables, and maintain active licenses / certifications as deemed required by minimum requirements for position, e.g., maintain sufficient knowledge of TJC, Federal and State regulations and PRO activities to ensure hospital and medical staff activities are in compliance with regulations.

General Department Specific Functions

Performance Specific Assignments:

Provide clinical management of quality performance metrics for the medical group practice as assigned. Work closely with the performance analytics and decision support unit for seamless collaboration in all endeavors pertaining to performance metrics and quality programs. Work closely with senior management and the departmental performance analytics unit in the development, attainment, and evaluation of metrics /outcomes, and make recommendations. Educate faculty, administration and staff in regulatory requirements and provide guidance on how providers and TINS can improve performance. Collaborate with Director of Quality Performance Analytics to identify opportunities to maximize the training and communication of governmental programming requirements, and facilitate the implementation of the accepted recommendations. Identify which cases meet established criteria for clinical case review through assessment of information from various data systems. Responsible for the overall clinical management and communication of quality performance metrics for the University of Miami Health System, e.g., individual providers, TINs, and medical group practice. Maintain familiarity with provider workflows at UHealth which impact quality performance. Participate in the development of UHealth quality performance reports and Dashboards. Collaborate with interdisciplinary healthcare professionals on hospital driven processes, which may include medical staff peer review; OPPE/FPPE, clinical database coordination; team/task force development and facilitation; maintenance of policies and procedures and continuous accreditation readiness.

General Departmental Responsibilities:

Analyze findings, perform trend analysis, and implement appropriate interventions to demonstrate improvements in quality outcomes and patient satisfaction. Collaborate with a broad range of clinicians and professionals on quality improvement initiatives and quality of service provided, and take responsibility to lead the implementation of quality improvement initiatives and quality outcomes for the assigned service line/group. Collaborate closely with departmental directors to apply clinical knowledge and expertise; advanced critical thinking, coaching and teaching, skills and knowledge of performance improvement tools, techniques and processes to a variety of federal or state mandated quality reporting programs, or other regulatory agency. Collaborate with interdisciplinary healthcare professionals on hospital and/or practice driven processes to ensure departmental metrics, and national measures and standards are being met. Develop and/or continuously monitor an internal reporting structure for quality management and related activities, and ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process. Facilitate clinical improvement activities, inclusive of nursing sensitive indicators, cancer core measures, and inpatient and outpatient core measures. Monitor patient safety activities to improve and enhance care delivery. Create and/or maintain effective and efficient systems, primarily those having a direct impact on the health care system enterprise and patient care. Train, educate, and communicate to providers and staff individually, in small groups, or in large workshop / clinical meeting settings. Apply best practice knowledge to quality improvement efforts, and educate faculty, administration and staff in the identification of opportunities for improvement and methods of collecting, analyzing, and reporting of findings and improvement strategies. Ensure accuracy and validation of unit's work product and submissions, and provide effective coaching and training to collaborators in order to successfully meet established standards of excellence and metrics. Prepare comprehensive documentation to support all related activities, and prepare briefings and reports as requested. Assist with reports and presentations for departmental committees, meetings, and projects. Participate in meetings on behalf of Patient Safety and Quality Department; Serves as a clinical subject matter expert on quality metrics, in support of CPSQO and Quality leadership team. Work as a team member to meet departmental goals and state and national reporting goals. Serve as a reliable resource to clinic staff, physicians, and patients on matters related to maintaining compliance per established standards. Participate in professional development opportunities and required meetings, trainings, and committees. Accountable to respect the rights and privacy of others at all times, including the confidentiality of patient information in accordance with established administrative policies and procedures, regulatory standards and guidelines, and governmental rules and regulations. Provide auxiliary support to other clinical quality professionals within the department.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.<...