Quality-Patient Safety Program Manager

CHI Health Immanuel located in North Omaha just off of I-680 on 72nd Street offers a full-service hospital cancer center rehabilitation center specialty spine hospital and more. For well over a century our commitment to serve our community inspires our staff to provide the highest quality of care to all who we have the privilege to serve.

CHI Health Immanuel will consider both licensed and non-licensed candidates for this position. Please note that the pay range will vary based on the candidates licensure status.

The primary function of the Quality/Patient Safety Program Manager is to support coordinate and facilitate the quality management (QM) patient safety (PS) and regulatory performance improvement (PI) activities for the hospital and medical staff. This role also serves as a resource to employees management nursing directors senior management councils physicians and teams on quality management activities and will handle patient
sensitive and confidential hospital information.

Assists in the design planning implementation and coordination of Quality Management Patient Safety and Performance Improvement activities for assigned hospital and medical staff departments committees divisions service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives including but not limited to activities focused on clinical quality improvement patient safety and risk reduction patient
experience efficiency FMEAS root cause analyses and medical staff improvement (e.g. case review for peer review
OPPE FPPE).

Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP TJC Leapfrog etc. data collection and reporting of process and outcome measures. Facilitates development and implementation of data collection tools and processes including the ability to: identify data elements needed to complete appropriate measurement perform data collection and abstraction per specifications and validate data prior to submission or preview reports prior to
publication.

Facilitates meetings presents data and reports identifies key findings and assists with action plans and implementation.

Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers.

Licensed Registered Nurse Licensed Clinical Pharmacist or other Licensed Clinical Staff and three (3) years clinical experience in an acute care setting

Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction

One (1) year healthcare-related quality management/performance improvement experience (e.g. chart audit PI team member etc.)

Current state license in a clinical field in state of practice.

Certified Professional in Healthcare Quality (CPHQ) or Healthcare Quality and Management Certification (HCQM) or Certificate of
Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.

OR