Responsible for collecting, organizing, analyzing and presenting data about the hospital's performance in order to provide statistically valid information that may be utilized to improve overall performance. Facilitates performance improvement activities and quality improvement activities throughout the facility. Acts as a resource person to administrative team, department managers and medical staff. Assists with all regulatory body surveys; State Licensing Review, (CMS) Validation Surveys, etc.

EXEMPT

Effectively collects and aggregates data.

Effectively performs accurate statistical analysis and compilation of reports to facilitate data review.

Collects, analyzes and compiles reports from individual incident reports and occurrence information to allow for priority processing of performance improvement activities.

Able to review and analyze internal data reports, reports from external sources, i.e., CMS performance measures, event reporting, information from state and federal sources, and current literature.

In conjunction with the department manager reviews and analyzes data to assist with presentation of data that allows for risk analysis and assessed progress toward stated goals.

Is a reporting member of applicable committees on data findings, actions and monitoring. Is present at committees to serve as a data resource individual. Supports the committee meetings by collecting and formulating relevant information in such a way that decision making is facilitated.

Effectively works with clinical data/database related to the facility's quality improvement program; reports to the department manager for administrative control.

Provides timely reports that summarize the results of performance improvement programs; assesses the effectiveness and quality of said programs and redesigned processes.

Prepares reports as requested.

Formats quality improvement data in charts and/or graphs with accompanying analysis, summary and findings.

Responsible for collecting and analyzing data required for Federal and state reporting pertinent to quality improvement and infection prevention for the managed care environment and insurers as appropriate.

Assists with preparation for all regulatory surveys; State Licensing Review, (CMS) Validation Surveys for the system etc.

Demonstrates knowledge and competence in statistical data management and analysis.

Demonstrates knowledge and competence in data management via electronic environment, including charts, graphs, grids and other accepted forms of data collection, analysis and display.

Demonstrates knowledge of current methodologies and practices. Maintains an awareness of changes in regulation and requirements of accrediting bodies for the facility.

Makes recommendations to improve the facility's data base management, software, etc.

Provides support and assistance to medical staff officers, committee chairs and leadership as related to data information, as required and requested.

Maintains current knowledge of hospital policies, (CMS) standards, local, state and federal rules and regulations.

Participates in risk management and safety activities related to data management as requested.

Consistently demonstrates a professional, self-directed, mature, disciplined, and tactful approach to department responsibilities.

Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.

Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.

Track and trend patterns of non-compliance with CMS quality metrics and performs other analytic duties at the direction of the department manager.

Communicates appropriately and clearly to physicians, staff and department leadership as well as other team members.

Serves as a back up resource for policy and procedure data base administrator and other team members as assigned

Works collaboratively with the Quality, Patient Safety and Infection Prevention team.

Creates and develop focus studies for leaders and providers across the system as requested.

Adheres to dress code.

Completes annual educational requirements.

Maintains regulatory requirements.

Wears identification while on duty.

Maintains confidentiality at all times.

Attends department staff meetings as required within the department.

Reports to work on time and as scheduled; completes work in designated time.

Represents the organization in a positive and professional manner.

Actively participates in performance improvement and continuous quality improvement (CQI) activities.

Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards

Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.

Complies with Benefis Health System Organization Policies and Procedures.

Complies with Health and Safety Standards and Guidelines.

Effectively collects and aggregates data.

Effectively performs accurate statistical analysis and compilation of reports to facilitate data review.

Collects, analyzes and compiles reports from individual incident reports and occurrence information to allow for priority processing of performance improvement activities.

Able to review and analyze internal data reports, reports from external sources, i.e., ORYX and Core Measure performance measures, occurrence reporting information from state and federal sources and current literature.

Works in conjunction with the department Director, management, reviews and analyzes data to assist with presentation of data that allows for risk analysis and assessed progress toward stated goals.

Is a reporting member of applicable committees on data findings, actions and monitoring. Is present at committee to serve as a data resource individual. Supports the committee meetings by collecting and formulating relevant information in such a way that decision making is facilitated.

Effectively works with clinical data/database related to the facility's quality improvement program; reports to the department Director for administrative control.

Provides timely reports that summarize the results of performance improvement programs; assesses the effectiveness and quality of said programs, redesigned processes.

Prepares reports as requested.

Formats PI data in charts and/or graphs with accompanying analysis, summary and findings.

Responsible for collecting and analyzing data required for NCQA, HEDIS and state reporting pertinent to quality improvement for the managed care environment, as appropriate.

Assists with preparation for all regulatory surveys; State Licensing Review, HCFA (CMS) Validation Surveys, etc.

Demonstrates knowledge and competence in statistical data management and analysis.

Demonstrates knowledge and competence in data management via electronic environment, including charts, graphs, grids and other accepted forms of data collection, analysis and display.

Demonstrates knowledge of current methodologies and practices. Maintains an awareness of changes in regulation and requirements of accrediting bodies for the facility.

Makes recommendations to improve the facility's data base management, software, etc.

Provides support and assistance to medical staff officers, committee chairmen and Governing Body as related to data information, as required and requested.

Maintains current knowledge of hospital policies, HCFA (CMS) standards, local, state and federal rules and regulations.

Participates in risk management and safety activities related to data management as requested.

Consistently demonstrates a professional, self-directed, mature, disciplined and tactful approach to department responsibilities.

Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.

Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.

Adheres to dress code.

Completes annual educational requirements.

Maintains regulatory requirements.

Wears identification while on duty.

Maintains confidentiality at all times.

Attends department staff meetings as required within the department.

Reports to work on time and as scheduled; completes work in designated time.

Represents the organization in a positive and professional manner.

Actively participates in performance improvement and continuous quality improvement (CQI) activities.

Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards

Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.

Complies with Benefis Health System Organization Policies and Procedures.

Complies with Health and Safety Standards and Guidelines.