QA -Quality Measures RN Manager, Decatur

Decatur, Texas
Commensurate with Experience + Benefits
Jan 29, 2018
Feb 28, 2018
Contract Type
Full Time

Summary of Responsibilities:

  • Participates as Quality Net and Joint Commission liaison as well as CMS reporting subject matter expert regarding quality performance measure and issues Collaborates with other Managers and Directors regarding process improvement issues and reporting Attends meetings to communicate Indicator Outcomes; reports Outcomes on a quarterly basis and communicates issues or regulatory requirements Oversees the compilation and ensures accuracy of Quarterly Dashboard and presents reports to Administration as well as to Medical and Clinical Staff Revises and explains specifications manual information as related to Physicians, Managers, and Administration Oversees the development of educational handouts/posters with important information as related to Staff/Physicians Oversees the compilation of data and ensures accuracy of Quarterly Dashboard and presents each to Administration, Medical and Clinical Staff Assists with the planning and implementation of interventions to ensure best practice for quality indicators such as Sepsis and Stroke Revises protocols, procedures, and improvement processes to ensure hospital remains in compliance with regulatory guidelines Responsible for oversight of reporting which includes report compilation to analyze cases for measure compliance and process improvement issues Oversees the tracking and alignment of data through missing cases, rejected cases, and unresolved case or registry reports Ensures data is reported within required timelines and that the submitted data is validated, reviewed for failures, accuracy, and/or issues prior to submission deadlines Maintains knowledge of and actively participates in hospital Core Measure, Value Based Purchasing, and Hospital IQR, OQR, IPFQR  requirements Oversees daily concurrent and/or retro case abstraction; data entry analysis for hospital compliance and performance of Quality Measure Guidelines Reviews Specifications Manual and oversees education of staff and clinical personnel regarding  of quality measure and registry changes which directly affect them Responsible for Quality Net reporting; including but not limited to data submission and feedback reports, compliance issues, participation, status changes, and notifications  Maintains inter-rater reliability, validation of OFI's,  and inter departmental PI projects Works closely and communicates with Director and Coordinator to maintain cohesiveness within the department Participates in Registry meetings as back up as needed Commitment to quality and achievement of excellence with the ability to utilize process improvement methods Experience with computer applications including hospital and PC based applications Must work autonomously with advanced level organizational skills and the ability to work under pressure, prioritize tasks, as well as exhibit time management skills High level Oversight/Management of department daily needs to ensure that the department runs smoothly; demonstrate critical thinking and decision making Demonstrated strong communication and interpersonal skills; ability to project a positive image of self and organization Protects and keeps all information confidential  Maintains professional credentials Performs other job duties as assigned  



  • Operationally, reports to the Director of Quality Measures/Registries 


  • 1)  Current Texas license to work as a Registered Nurse and a graduate of an accredited School of Nursing.  2)  Minimum 3 years of experience in acute care of medical/ surgical nursing.  3)  Two years of recent experience in a medical business office, or hospital setting.

Must have current licensure/certifications upon hire.

  • There is an occasional risk of exposure to mucous membranes or skin contact with blood, body fluids, or tissues, or a potential for spills or splashed during the performance of the job.  Universal precautions must be observed and protective devices worn by the employee when performing a task that is likely to cause exposure.

Employment standards include current requirements as determined by Federal, State, and Wise Health System policy.
Employee status:

  • Hourly Salary



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