Clinical Quality Reviewer-Pedi NSQIP

Quality & Safety, Houston, Texas
Dec 06, 2017
Dec 31, 2017
Contract Type
Full Time
Clinical Quality Reviewer-Pedi NSQIPQuality & Safety

Job Description
Memorial Hermann Health System seeks a Clinical Quality Reviewer-Chart Abstractor for our Pediatrics NSQIP team. Experience with Chart Abstraction is highly desired.

The Clinical Quality Reviewer is responsible to collect and submit reliable data to the indicated registries and/or databases. This position assures appropriate data collection, abstraction, analysis and reporting of noted measures and communicates changes in definitions, methodology, and mandatory requirements. This position will support the quality and patient safety improvement efforts through data abstraction and inputting into the appropriate system.


Education: Bachelor of Science in nursing highly preferred or a combination of four (4) years of training and experience. 

Experience:  Three (3) years of clinical experience to ensure knowledge base sufficient to support clinical performance improvement initiatives.

Clinical chart review and abstraction experience a plus.

  • Current State of Texas RN license to practice professional nursing.

  • Non-RN practitioners must hold: Licensed vocational nurse or nurse practitioner (LVN/LPN) or Registered Health Administrator (RHIA) or Registered Health Information Technician (RHIT).

Understanding of quality improvement, performance improvement or patient safety knowledge preferred. 

Ability to locate information in various sources to gather data in a complex hospital system environment.

Clinical knowledge of assigned clinical conditions and physiological systems to discern the impact of specific indicators on outcomes and to identify potential gaps in clinical care processes.

Ability to interact with all members of the healthcare team and administrative staff in a professional and courteous manner. Ability to build relationships and gain alignment for clinical support from superiors and peers.

Demonstrated proficiency in computer operation, MS Office products (Word, Excel, PowerPoint).

Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principle Accountabilities:

Collects and submits data in a systematic way to all indicated registries and databases. 

Identifies opportunities for performance improvement based on reliable data trending; recognizing and analyzing undesirable patterns or trends in performance.

Works in conjunction with hospital Quality Patient Safety and Infection Control teams to implement and revise the Performance Improvement Plan for designated campuses as needed.

Participates in performance improvement activities.

Maintains the requisite skills to complete analysis on data points that will drive performance improvement.

Attends meetings as needed to ensure reliable data collection of core measures.

Demonstrates applicability of the core measures methodology and the reliability of definitions utilized by reviewers through Inter-Rater Reliability (IRR) testing.

Effectively utilizes software applications for data collection and analysis.

Accountable for accurate and timely entry of data into the database and meeting caseload requirements.

Responsible for timely communication with clinical providers and stakeholders when gaps and/or fall-outs in clinical processes are identified.

Serves as an educational resource on the core measures methodology and algorithms for internal and external audiences by developing educational materials and delivering presentations.

Adheres to all Memorial Hermann policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.

Demonstrates the ability to collaborate with others to achieve desired work results.

Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.

Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

Other duties as assigned.

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