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Data Management
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Demonstrates proficiency the use of electric systems for the storage and retrieval of data to be used in reports disseminated throughout the organization and for submission of data to regulatory and third party agencies.
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Maintains schedule of deadlines and assures completion of preparatory work required for collection and accurate submission of data based on those deadlines.
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Works collaboratively with Information Systems, Decision Support staff and outside vendors to maintain, update and troubleshoot electronic systems for confidential collection and submission of data to outside agencies (includes but is not limited to: Centers for Medicare and Medicaid Services (CMS), patient satisfaction vendor (Press Gamey), QualityNet, Accountable Care Organizations (ACOs), Hospital Improvement and Innovation Network (HIIN), Dartmouth-Hitchcock Health (D-HH), Medicare Beneficiary Quality Improvement Project (MBQIP), New Hampshire Healthcare Quality Assurance Commission).
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Generates monthly reports to identify CMS cases for review. Prepares initial documentation of CART paper or electronic tools for clinical review. Input data for CMS cases into CART and securely submit data to CMS prior to strict deadlines.
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Generates reports, reviews data for accuracy, and submits patient data to patient satisfaction vendor per vendor guidelines and deadlines on an ongoing basis.
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Generates monthly and ad hoc reports to support provider peer review processes. Coordinates review process and generates final reports for section chairs. Maintains files for completed peer review documentation to support provider credentialing process.
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Supports required data submission requirements for grants or accreditation programs.
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Prepares data-driven reports for performance improvement and patient safety initiatives.
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Demonstrates logical and critical review of data and systems to assure accuracy of data and reporting.
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Demonstrates proficiency in computer software to create and update reports, display data effectively and create efficient systems for collection and retrieval of data.
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Provides assistance and education to departments and teams in the design of data collection and reporting tools and processes to support quality improvement initiatives.
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Develops and maintains systems for tracking report development to minimize redundancy and ensure consistency across users of extracted data.
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Monitors external reporting agencies to identify changes in reporting requirements and make changes in data extraction and collection processes as needed.
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Works carefully and precisely, with attention to detail.
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Communication
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Interacts and collaborates regularly with a wide variety of internal and external customers.
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Communicates effectively with patients, visitors, co-workers, leaders and external customers; takes action to clarify information received from others.
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Takes initiative to proactively follow through on duties and commitments.
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Handles confidential or sensitive material; exercises judgment and discretion concerning its disposition.
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Quality Improvement Program Management
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Is facile in the various quality initiatives and activities throughout the organization.
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Participates as requested in quality initiatives and programs.
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Utilizes Quality Improvement processes and tools to foster and support organization change.
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Supports survey-readiness activities throughout the organization.
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Stays current with methodology and practices, and maintains awareness of regulatory changes and requirements of accrediting bodies.
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Coordinates the annual appraisal of the organization-wide Quality Program. Collects support documentation throughout the year. Assures inclusion of all data required by CMS Conditions of Participation (CoP's) for Critical Access Hospitals (CAH's).
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Participates in appropriate committees related to safety, information systems, quality improvement and infection control.
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Research and provide analysis, summary and best practice suggestions for new initiatives.
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Other duties as assigned.
