Job Description
Located in beautiful Northern California, Adventist Health Clear Lake has been a leading healthcare provider in Lake County since 1968. We are comprised of a 25-bed critical access hospital and provide primary and specialty care services at clinics throughout the area to best serve our community. Lake County is home to Clear Lake, California's largest natural freshwater lake, surrounded by charming small towns, beautiful mountains, vineyards and orchards. This area is perfect for outdoor enthusiasts, with some of the best bass fishing, rural trails for hiking and biking, all the while being only two hours from the San Francisco Bay Area, Sacramento Valley or Pacific Coast.
Job Summary
Coordinates the ongoing development and implementation of organization wide quality improvement activities. Collaborates with hospital leadership, staff, physicians and information systems in facilitating specific job activities to achieve organizational goals. Assists in the coordination of studies performed within the Quality Assurance program and prepare reports as required.
Job Requirements
Education and Work Experience:
- Bachelor's Degree in Nursing (BSN): Preferred
Licenses/Certifications
- Registered Nurse (RN) licensure in the state of practice: Required
Essential Functions
- Prepares first level analytical and statistical reports for the department. Maintains information systems and report results regularly to the department director and appropriate leadership, physicians and staff. Assists with the maintenance of the company's quality assurance program and identifies opportunities to improve patient care within the center.
- Conducts concurrent and retrospective chart audits and data extraction and focused studies as assigned. Assists in the planning, organization and direction of Quality Assurance programs and related activities. Develops and maintains a calendar of chart review activities, including focus studies. Ensures chart reviews are timely, accurate, and meet all data requirements for JCAHO, CMS, Medical Staff and the Board Quality Council and Governing Board.
- Is responsible to perform initial screening and analysis of reported events, conduct data abstraction, and assist in facilitating meaningful Medical Staff case review documentation. Monitors physician specific tracking, trending and reporting and provides assistance in abstracting and aggregating physician specific OPPE data in accordance with the credentialing process.
- Monitors compliance with both internal standards and regulatory requirements and makes recommendations for the adjustment of company programs accordingly. Develops and implements appropriate plans of action to correct identified deficiencies as needed.
- Identifies peer review cases through internal and external sources as appropriate. Collaborates in planning, implementing, and evaluating department activities. Assist Department Heads and staff in the evaluation of programs and effect changes as necessary to improve programs and assure compliance with regulatory requirements.
- Performs other job-related duties as assigned.
Organizational Requirements
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
About Us
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 90 communities on the West Coast and Hawaii with over 400 sites of care, including 26 acute care facilities, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of 37,000 includes employees, physicians and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.