Quality Assurance Analyst (Relief)

Pay range: $27.20 - $40.79 per hour, based on experience.
This relief position is eligible for a 15% differential on top of the base rate in lieu of benefits.

In addition, this role is eligible to work remotely from an approved state by St. Charles (please refer to the list). If you do not reside in an approved listed state (or do not plan to relocate to an approved listed state) we request, you do not apply for this particular position.

Approved states by St. Charles: Oregon, Arizona, Arkansas, Florida, Idaho, Missouri, Montana, Nevada, New Mexico, North Carolina, Oklahoma, Tennessee, Utah, and Wisconsin.

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE:                                      Quality Assurance Analyst   

REPORTS TO POSITION:       Quality Improvement and Data Manager

DEPARTMENT:                         Quality Management

DATE LAST REVIEWED:          January 4, 2024

OUR VISION:                           Creating America’s healthiest community, together

OUR MISSION:                        In the spirit of love and compassion, better health, better care, better value

OUR VALUES:                          Accountability, Caring and Teamwork

DEPARTMENT SUMMARY: The Quality Management (QM) department provides essential services to St. Charles Health System (SCHS) including: quality improvement expertise and support; data analysis; regulatory affairs, accreditation and licensing expertise and support; environment of care safety programming, expertise, and support; emergency preparedness; policy and document library management and support; data abstraction; integrity of clinical documentation; the patient experience and grievance program; and risk management and patient safety program.

POSITION OVERVIEW: (The Quality Assurance Analyst is to abstract and submit reliable EHR data into quality registries and programs or other national regulatory programs as assigned with proficiency in compliance with registry and regulatory guidelines. This position provides routine and ad hoc registry and program reports for clinical and administrative leaders related to the specific database programs being utilized. They serve as the primary internal resource for clinical and administrative leaders on data documentation requirements, regulatory quality measure definitions, and statistical reports related to the specific database programs being utilized. This position does not directly manage any other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Data Abstraction

• Core Measures

  • Inpatient -PC-01 and Sepsis to CMS, PC-02, PC-05, PC-06 to Joint Commission quarterly

  • IPFQR annually and Restraint and Seclusion, Length of Stay Days (LOS) quarterly to CMS

  • Outpatient: OP-22, OP-29, OP-31 annually, OP-18, OP-23 quarterly to CMS

• Structural Measure -Maternal Morbidity CMS annually

• Hybrid Hospital-Wide Readmission (HWR) and Hybrid Hospital-Wide Mortality (HWM) measures

• Emergency Department Transfer Communication to MBQIP quarterly

Data Submission/ Reporting

• eCQM to CMS and Joint Commission annually

• Promoting Interoperability annually to CMS

• Validation of COVID and HCAHPS data via Premier to CMS

• Provider Participation reports quarterly for CMS data submissions

• Pepper biannual reporting

• Core measure reporting monthly and quarterly

• QualityNet (CMS) downloads to Premier portal x24

• Validate Premier error reports monthly and coordinate with multiple departments to reconcile

Interrater Reliability for Stroke data Get with the Guidelines (GWTG) monthly

Ongoing Provider Professional Evaluation (OPPE regulatory) reports biannually in Premier

NDNQI Site Coordinator for data submission on the following measure

• Assaults on nursing personal, Births data, Lactation consultant hours, Nursing Care Hours, Patient Days, ED patient volume, Patient Falls monthly

• Additional measure indicators and reporting to internal stakeholders

• Quarterly reports

• Validate hospital demographics

• Updating users, access and assign tutorials

Utilizes software applications and is able to navigate and abstract data from EPIC, CMS HARP, QualityNet, Premier, NDNQI, Power BI, Epic Reports and other EHR electronic applications for data collection and analysis.

Remains current with specific assigned registry and regulatory data collection guidelines and measures definitions through list serves, webinars, specifications, and other tools.

Contacts database vendors for assistance with standards interpretation when necessary.

Provides accurate and timely regular and ad hoc reports to St. Charles leadership, improvement teams, external regulators, and others as requested.  May be required to present data and findings to leadership team, stakeholder meetings, etc.

Assists with quality data updates and measurement change meetings with St. Charles leadership, improvement teams, and others as necessary. Travels to other SCHS facilities as necessary.

Supports the vision, mission and values of the organization in all respects.

Supports the Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality.  Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate. 

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION:                   

Required: High school diploma or GED.

Preferred: N/A 

LICENSURE/CERTIFICATION/REGISTRATION:

Required: RHIT Certification and ongoing maintenance of required education credits (CE) through AHIMA

Preferred: N/A

EXPERIENCE:

Required: One-year experience in one of the following settings: healthcare data entry or registry work, hospital or clinic role, or medical records/HIM. Medical terminology. Experience in data entry with basic Word and Excel proficiency.

Preferred: Quality improvement or patient safety knowledge and experience. Clinical chart review and abstraction experience. Basic statistical knowledge.             

PERSONAL PROTECTIVE EQUIPMENT:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%):  Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%):  Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

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