Manager of Performance Improvement Full-time with Benefits

Job Summary

Supports and is responsible for incorporating into job performance the Frederick Health (FH) mission vision core values and customer service philosophy and adheres to the FH Compliance Program including following all regulatory requirements and the FH Standards of Behavior.

Reporting to the Director of Performance Improvement (PI) the Manager of Performance Improvement (PI) is responsible for providing leadership and support across the organization in all aspects of the area of the performance improvement process. The Manager is responsible for internal monitoring and reporting of specific clinical and performance indicators. He or she works with leaders and facilitates teams in the identification of benchmark data for project goal and target setting. The Manager supervises performance improvement projects in alignment with Frederick Health goals and objectives and provides quality improvement educational activities and information to committees departments and/or individuals. The Manager develops data management strategies for clinical information capturing and support of other organizational priorities. The Manager is responsible for the transfer of data and information from the Meditech System to Premier for the quality monitoring and reportable data and validating accuracy of the data and data addition the Manager will oversee the daily activities of the Clinical Documentation Improvement Specialists within the Performance Improvement Department. This person will facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity actively present during the patients encounter. This manager is responsible for development and execution of the clinical documentation improvement process must be knowledgeable of program metrics and serves to ensure data is timely and accurately reported. The Manager understands the CDI /coding data base and ensures optimization of 3M -360 applications.

The Manager provides administrative direction for the departments operations budgeting development of information systems and coordination of information flow. The Manager supports and is responsible for incorporating into job performance the Frederick Health mission vision core values and customer service philosophy and adheres to the Frederick Health Compliance Program including following all regulatory requirements and the Frederick Health Standards of Behavior.

Example of Essential Functions:

• Participates in and provides leadership to the establishment implementation and maintenance of the organizations clinical quality improvement strategies programs and methods
• Develops implements and monitors effectiveness of quality strategies and plans
• Designs and coordinates communication of clinical quality improvement activities and outcomes and results to enhance programming
• Communicates concepts and issues effectively (written and oral) across all service lines within the organization
• Able to convert data into actionable information
• Coach train and develop teams to create processes to consistently achieve best practices that is evidence based
• Facilitates problem-solving within and between program area
• Provides organizational leadership for the design implementation and maintenance of quality outcomes and databases such as core measures disease specific indications MHACs physician peer review clinical registries and quality indicators that will contribute to process improvements and reimbursement from the HSCRC while improving the quality of care throughout the continuum of care
• Participates and supports medical staff and committees and facilitates intra-disciplinary workgroups focused on clinical care
• Manages the process for the Physician Peer Review process including MROC and other physician peer review Committees
• Responsible for understanding scope of quality data program wide and coordinating data collection methods and approaches
• Develops and maintains consistent valid and reliable databases for clinical outcomes reporting and other data usage
• Assumes program-wide responsibility and accountability for the management of the Premier database registries and other data systems
• Monitors the aggregation disbursement and reporting of all clinical and quality data
• Coordinates a comprehensive data management process to supply data in a timely manner to support of continuous quality improvement and process improvement
• Performs detailed data analyses of clinical trends and identifies areas of opportunity to improve quality safety throughout the organization
• Provides quality reports and metrics to stakeholders in an ongoing and ad hoc basis
• Identifies appropriate national and state databases for comparison of quality outcomes data
• Prepares management reports for the Quality Coordinating Council Medical Review Oversight Committee (MROC) and other key management meetings
• Reports System performance to state and federal agencies as required
• Develop and share best practices for improving performance in quality safety perception of care value and efficiency as related to the organizations Quest initiatives
• Provides daily oversight of the Clinical Documentation Program
• Works with hospital leadership physicians and other providers to improve the overall quality and completeness of clinical documentation in the medical record to ensure that an accurate reflection of the severity of illness and the quality of care is captured
• Works to educate providers on the value of more granular documentation to their quality scores risk of mortality data length of stay and continuity of care for the patient
• Serves as a translator between Finance and the Clinical Staff and plays a vital role in improving accurate quality reporting for both provider and the facility
• Collaborates with the Coding Manager to ensure that accurate DRG-based reimbursement for the hospital is achieved and claim denials are reduced by ensuring documentation integrity
• Principal resource for compliance with accrediting and regulatory agencies as they apply to the medical staff organization
• Assists the medical staff leadership with achieving its objective to maintain quality and improve performance
• Maintains excellent communication with administration and other relevant departments.
• Assists medical staff members when requested and provides necessary reports to medical staff administration and other departments as required
• Creates and maintains a positive work environment by being responsible for all aspects of personnel management from recruitment staff development create job performance standards conduct performance evaluations evaluate workload promote optimal productivity team building identify/provide excellent customer service resolve staffing issues counsel personnel and following the process for disciplinary action when warranted
• Responsible for the development and monitoring of the annual budget for the Performance Improvement Department
• Controls dissemination of all communication between the hospital medical staff leadership and/or hospital departments to the medical staff members related to quality improvement
• Plans evaluates and improves the efficiency of processes and procedures to enhance speed quality efficiency and results
• Monitors and measures productivity goal achievement and overall effectiveness of the department
• Prepares periodic reports for management to track goal accomplishment
• Collaborates with IT to determine how new information technologies can support reengineering processes
• Implements process improvement projects through cross-functional departmental involvement
• Provides expertise in Lean/Six Sigma analytical and statistical tools and project oversight and management

Required Knowledge Skills and Abilities:

• Knowledge of company policies and state/federal regulatory and accreditation standards.
• Knowledge of Lean/Six Sigma methodologies.
• Ability to work with or lead interdisciplinary teams.
• Ability to build and maintain professional knowledge
• Excellent communications skills both verbally and written.
• Ability to create collaborative working relationships
• Ability to create and maintain a participatory environment.

Minimum Education Training and Experience Required:

• Bachelors Degree in Nursing or other related field. Masters preferred. Green belt in Lean Six Sigma or within one year of hire.
• Five years work experience in a healthcare setting required.
• CPHQ or HACP certification required.
• Licensed Registered Nurse in the state of Maryland; Five years of experience in training and/or performance improvement; Team facilitation and experience with hospital performance improvement.

Caring for you as you care for the CommUNITY
Frederick Health offers a comprehensive and affordable benefits package. Health Dental and Vision insurance are offered the 1st of the month after 30 days of employment to all employees hired to work at least 20 hours per week and offer multiple plans to best meet you and your family needs. Life insurance Short-Term Income Replacement and Long-Term Disability are employer paid for eligible employees. Frederick Health offers a robust Paid Time Off program for eligible employees. Our 403B retirement plan helps you save for your retirement and includes an employer match to eligible employees. All employees have access to free financial planning sessions. We also offer an educational assistance program to support your education goals as well as an employer paid Employee Assistance Program.

Pay is based on experience skills and education. Exempt positions under the Fair Labor Standard Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on specialty if applicable. Non-Exempt positions may have shift differential and/or Overtime paid if applicable.

Salary Range: $85987.20 - $129708.80

Hours: Monday through Friday dayshift 8am-430pm with flexibility in hours. Some evening or early meetings required.

Required Experience:

Manager