The Performance Improvement Manager will oversees hospital wide identification, collection, analysis, and public reporting of data to TJC and CMS for quality measures. This position serves as a key resource for data and information to be used in hospital wide performance improvement and medical staff OPPE. The position shall assist with data requests and reports from the Midas DataVision and Clients Only Website.
The position works collaboratively with the Coding Department, CDI, and Patient Registration to ensure accurate data is submitted to CMS and other third parties as it relates to data elements for quality measures that impact the hospital quality and payment initiatives.
Job duties include but are not limited to the following:
Develops and presents performance reports to committees, medical staff sections, and Performance Measurement/Improvement.
Provides information and works collaboratively with the Midas System Administrator, the Medical Staff Credentialing Coordinators and others to provide data and reports to support physician-credentialing processes for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE).
This position will assist the director in follow-up with Quality Issues from WVMI, Blue Cross and other entities.
Performs function of Quality Net Exchange Security Administrator, and one of the key contact for the Midas/Xerox suite of products.
Reviews daily reports for admissions and discharges to ensure correct statuses are entered into system.
Reviews daily reports for all coded inpatient and outpatient cases with a focus for complications and appropriate assignment of codes that impact our quality data, physician attribution, Patient Safety Indicators, CMS Star Rating, Value Based Purchasing, Healthgrades and Leapfrog Scores.
Reviews cases and prepares initial notification to appropriate individuals for potential litigation or peer review cases. Assists the Director of Quality and Performance Improvement with responses for interrogatories.
Prepares data analysis and comparison with local hospitals (or others as requested by Senior Leadership) for Hospital Compare, CMS Stars, Healthgrades, and Leapfrog data.
Provides reports on demand for TJC, CMS, and other surveys.
Uses Midas’s tools such as worklists to identify potential quality issues and provides feedback as appropriate to departments and teams.
Bachelor' degree in clinical healthcare area required
WV RN license is preferred
Certified Professional in Healthcare Quality is preferred
Minimum of two years of position related experience required such as past experience exemplifying knowledge of data management, ability to analyze information; use of Word, Excel, and Power Point; knowledge of process improvement and statistical tools, excellent communication skills.
Additional Salary Information: Competitive salary and benefit package.
Internal Number: 560.0502_226
About Cabell Huntington Hospital
Cabell Huntington Hospital is a not-for-profit, regional referral center with 303 staffed beds. Located in Huntington, West Virginia, Cabell Huntington cares for patients from more than 29 counties throughout West Virginia, eastern Kentucky and southern Ohio. Opened in 1956, it is also a teaching hospital and is affiliated with Marshall University Schools of Medicine and Nursing.
All of us at Cabell Huntington Hospital share a common value - providing excellent care that promotes lifelong good health. Your medical care includes very personal attention to the details that help make all patients and their families feel at home.