CV Services Quality & Accreditation Coordinator

Augusta Health

About The Position

The Quality and Accreditation Coordinator for CV Services performs clinical auditing and data abstraction of patient records in support of Augusta Health’s clinical process improvement and patient safety initiatives associated with participating registries. Results of audits and identified trends are reviewed with CV leadership, clinical nurse specialists, unit-assigned clinical staff, performance improvement staff, and physician quality task forces. The QA Coordinator’s key responsibility is to collect and submit accurate, complete, and timely data for their assigned NCDR registries. This task is accomplished through high-quality data compilation, documentation, and data entry of identified procedures into the associated registry/vendor tool platform. The QA Coordinator also serves as an integral part of the CV Leadership’s team in ensuring that accreditation data is abstracted, submitted appropriately, and timely to various credentialing organizations thereby supporting the mission of Augusta Health. The QA Coordinator supports CV Leadership by assisting with the compilation of vital statistics to include volume data, STEMI data, interfacing with the EMS community, presenting QA data to senior executives at AH, and serving as the subject matter expert for CV Quality Data. QA Coordinator also performs other duties as assigned.

Requirements

Bachelor’s Degree required
Current BLS certification required
ACLS within 6 months of employment required
Minimum of 2 years of Cath Lab experience; or prior CV Quality experience required.

Nice To Haves

Master’s Degree preferred
Certified Medical Assistant, Licensed Practical Nurse or Emergency Medical Technician preferred
Minimum of one year of NCDR Data Abstraction preferred.

Responsibilities

Reviews 100 percent of NCDR CathPCI and/or Chest Pain/MI patients for inclusion in the applicable Data Registries as identified by the facility.
Collects preoperative, intraoperative, and 30-day postoperative follow-up data components for the program through the effective utilization of the hospital medical record systems.
Identifies streamlining and process improvement opportunities in the data collection process.
Responsible for the accurate, complete, and timely entry of data into the program’s database.
Maintain accuracy threshold of greater than or equal to 95 percent.
Serves as an educational resource on the NCDR Registry for internal and external audiences.
Clearly communicates any data documentation needs to support accurate and high reliable data collection and reporting.
Participates in NCDR educational opportunities as they related to their assigned position.
Apply specialized, clinical knowledge of hospital partners: categorize, code, summarize, interpret, and calculate registry/case information from nuanced, patient medical records.
Ensure quality submission of all data in specified registries or measure data repositories, maintaining a high accuracy threshold.
Prioritize, organize, and meet tight deadlines for multiple concurrent tasks and team requests; use tact and judgment to manage expectations, flag obstacles, and propose solutions in a timely manner.
Navigate new technical systems: electronic medical records (EMR) and registry/case entry tools; use team resources to troubleshoot technical issues and applications with a focus on solutions.
Contribute to team best practices, data dictionaries, abstraction guidelines, and other business rule documents; identify process improvement opportunities to help streamline tasks and processes.
Keeps up to date on mandated regulatory/publicly reported data requirements as specified by federal, state, payer, and other agencies.
Supports CV Leadership by assisting with the maintenance and submission of various accreditation packets to multiple professional agencies in the advancement of organizational mission to include accreditations and accrediting bodies.
Supports CV Leadership in the monitoring, maintenance, and creation of various reports outlining productivity, quality, and other metrics to support the fiscal health of the service line.
Presents key data elements to organizational leadership and outside agencies as required during quarterly quality meetings.
Support CV Leadership by assessing training needs of staff related to procedural documentation and mentoring team members on process improvement opportunities.
Performs all other functions as related to this job and assigned.