RN

17035BR

FTE: 1.0

Shift: All shifts, hybrid schedule.

Compensation: Commensurate with experience.

Hours Per Week: 40

Weekends: No

Benefit Eligible

The Clinical Performance Manager facilitates initiatives related to quality assurance and performance improvement (QAPI) in alignment with the organization's QAPI Plan and Quality Management System. The Clinical Performance Manager serves as a resource to others in the organization for quality improvement processes. The Clinical Performance Manager assumes accountability for overseeing internal and external clinical reporting systems and serves as a resource to others in understanding the impact of clinical outcomes measurement in relation to value-based purchasing agreements and public reporting mechanisms. The Clinical Performance Manager is responsible for managing the organization's participation in the Centers for Medicare & Medicaid Services (CMS) Quality Reporting Programs and various registries (e.g., NSQIP, VQI, GWTG) to ensure compliance with nationally recognized standards for quality patient care processes and clinical outcomes. The Clinical Performance Manager also oversees the Nursing Peer Review process, as well as Medical Staff Peer Review and Ongoing Professional Practice Evaluation processes for physicians, along with the Performance Improvement Department staff who perform this work.

At UnityPoint Health, you matter. We’re proud to be recognized as a Top Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.

Our competitive Total Rewards program offers benefits options focused on your needs and priorities, no matter what life stage you’re in. Here are just a few:

• Expect paid time off, parental leave, 401K matching and an employee recognition program.
• Dental, health and vision insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.
• Tuition reimbursement to help further your career and adoption assistance to help you grow your family.

With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.

And we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.

UnityPoint Health - Meriter and UW Health work closely together to deliver exceptional healthcare services to our community.

Join our team of experts and make a difference with UnityPoint Health.

Essential Functions:

• Responsible for developing, coordinating, implementing, and evaluating the continuous quality improvement activities by assisting in defining opportunities for improvement and collaborating with various internal and external participants to improve experience, satisfaction, and sustainable outcomes.
• Provide education in the area of quality improvement to departments, improvement teams, and providers and assists in ensuring compliance with regulatory and accrediting organizations.
• Facilitate Quality Assurance and Performance Improvement (QAPI) initiatives in alignment with the QAPI Plan and (e.g., Care Variation Reduction).
• Provide data for internal and external stakeholders (e.g., Insurance incentive programs.)
• Share reports with the hospital management on the performance of the Quality Management System and any need for improvement.
• Oversight of CMS Reporting Programs and voluntary reporting programs, including:
• Hospital Inpatient Quality Reporting Program: Core Measures, Claims-Based Measures, Hospital Acquired Infections (HAI), Hospital –Acquired Condition reduction, Hospital Value Based Program, Readmission Reduction, Promoting Interoperability
• Hospital Outpatient Quality Reporting Program
• Inpatient Psychiatric Facilities Program
• Various professionally affiliated registries
• Collaborative for Healthcare Quality publicly reported metrics
• Professional development and leadership responsibilities for direct reports (e.g., performance evaluations, time management/productivity, assignment of responsibilities).

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• Communicate key quality performance results and organizational impact to stakeholders.
• Communicate upcoming changes to regulatory quality reporting requirements to key stakeholders. 20% Medical Staff
• Oversee the Medical Staff and Nursing Peer Review process to maintain a standard and objective approach
• Oversee use and reporting of Medical Staff and Nursing Peer Review indicators (Chart Review and Rate & Rule Indicators)
• Ensure the Medical Staff Ongoing Professional Practice Evaluation Process meets requirement of the accreditation organization including the development and use of department/specialty specific metrics

Required Qualifications:

• BSN
• Previous experience with the Medical Staff Peer Review process.
• Minimum of two years of experience in a healthcare leadership role.
• Experience with process and performance improvement methods (e.g., PDSA, Lean, Six Sigma, change management).
• Experience in clinical outcome measurement, including acquisition of data from disparate sources.
• Experience working in a computer network environment, with proficiency in spreadsheets, databases, and word processing software.
• Valid RN license in the state(s) of practice, including eligibility under an NLC multistate license.
• Dual licensed positions: Team members must obtain and submit proof of dual licensure within 90 days of hire/transfer. Proof of application is acceptable during this period.
• Exceptional attention to detail and accuracy.
• Ability to exercise sound judgment and function independently.
• Strong verbal and written communication skills.
• Ability to manage multiple priorities and meet deadlines.
• Previous experience with spreadsheets, databases, and graphics software.
• Knowledge of CMS and accreditation.

EEO/M/F/D/V