General Summary

The Clinical Data Analyst prepares data queries and reports to support organization-wide Performance Improvement processes and programs. Collects and accurately enters data into spreadsheets, databases, charts and generates reports and analysis output related to exceptions and trends as directed to support PI efforts within the organization. Maintains aggregate databases/spreadsheets for use in quality review and utilization management; supports data related regulatory/accrediting body preparedness activities as directed.

Job Role

Clinical Data Analyst

* As Primary MIDAS System Administrator for the organization with focus on Ongoing Professional Practice Evaluations (OPPE) and will collaborate with department chiefs to measure OPPE standards.
* AS PRIMARY REVIEWER, SUPPORTS CORE MEASURES IMPLEMENTATION AS DEFINED BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) AND THE JOINT COMMISSION (TJC) TO SUPPORT OVERALL PI DATA SUBMISSION PROCESS: Supports the MHCC hospital performance evaluation guide requirements and the HSCRC quality initiative requirements that are consistent with Core Measures requirements from CMS/TJC. Supports data quality and integrity in the Core Measures review and submission process. Identifies appropriate cases for review based on Core Measures software specifications, requests medical records and conducts data review and abstracting of required data. Identifies potentially problematic data review and collection issues and seeks clarification as needed. Supports data quality and integrity in the Core Measures review and submission processes.
* COLLABORATES WITH QUALITY MANAGEMENT DEPARTMENT LEADERSHIP AND STAFF: Supports departmental goals, resource allocation on Performance Improvement projects, and assists in the successful completion of targeted department efforts, i.e. organizational preparation for regulatory reviews, etc. Consistently demonstrates knowledge and understanding of SJMC's current Strategic Quality Plan and utilizes the requirements therein as a guide to support multiple Quality Management / Performance initiatives and regulatory requirements. Demonstrates knowledge/appropriate application of "Just Accountability" related to fairness, equitable care, with honest reporting of adverse events when supporting QM initiatives. Demonstrates knowledge of the "Six Quality/Patient Safety aims": Safe, Timely, Effective, Efficient, Equitable and Patient Centered as they relate to QM initiatives.
* PROVIDES PLANNING, COORDINATION AND SUPPORT TO MEDICAL STAFF PERFORMANCE REVIEW COMMITTEES: Works with clinical department heads to understand the requirements of the performance improvement process for relevant departments. Conducts preliminary screening and review of cases and flags questionable charts for further review by nurse or physician. Manages cases for review by physicians through checking volumes, notifying physicians and providing technical support for case review via automated systems. Assures performance improvement initiatives are addressed, processed and followed-up at monthly meetings. Manages data and reports for presentation to PI committees. Provides additional data support related to available automated systems (EPIC etc.) to identify patient population or statistics related to PI activity.
* REPORTING / COMPLIANCE / RESEARCH: Fully knowledgeable of publically reported metrics: Core Measures, HCAHPS, Readmissions, HAC's, HAI's. Collaborates with QM PI Specialists in the delivery of core measures data metrics and trends for PI Team, Task Force/Work Group or Departmental intervention. Abstracts quality data from medical records for internally/externally reported/defined quality and patient safety measures. Ensures compliance with data entry and timelines established by 3rd party vendors. Performs research as needed to support QM initiatives, i.e. relevant articles, studies, etc., from valid, peer reviewed sources.
* WORKS WITH THE PI TEAM AND CLINICAL LEADERSHIP TO COLLECT, ANALYZE AND PRESENT DATA RELATED TO CMS/TJC CORE MEASURES AND MHCC/HSCRC DATA REQUIREMENTS: Creates accurate and timely queries and reports to address potential Performance Improvement processes and/or priorities. Streamlines data management and reporting and when possible, supports automation of new and existing PI processes to achieve greater efficiencies. Provides education and support to facilitate processes and data that will allow the user to independently access the information. Prepares data queries and reports to support the PI process. Uses Excel and other resources to aggregate, organize and present PI data.