JOB DESCRIPTION FOR JOB TITLE:



|MSC Quality Coordinator |

|Job Code: 300068 |FLSA Status: Non-Exempt |

|Mgt. Approval: M. Madden Date: 12.14.2015 |HR Approval: Date: 12/14/2015 |

|JOB SUMMARY |

|Responsible for using multiple resources to support quality control functions and improvement projects throughout the surgery center, as well as coordinating the |

|credentialing process. This position will be required to keep detailed data entry records and reports and is responsible for maintaining the integrity of MSC records. |

|Additional responsibilities include updating spreadsheets, preparing presentations, organizing department operations, and assisting with other duties as assigned. The |

|typical time allocation is 60% quality, 30% credentialing and 10% administrative. |

|MAJOR RESPONSIBILITIES |

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|Provide support to Management and the Medical Director(s), functions and procedures in compliance with AAAHC and CMS guidelines. |

|Initiates and coordinates the credentialing process of all Medical Staff and Allied Health Professionals in accordance with the MSC Bylaws, Governing Board and AAAHC |

|requirements, and State and Federal law including monitoring of Physician, and Allied Health Professional licenses and credential expiration dates. |

|Assists the Medical Director(s) with development of privilege criteria, privilege delineations, and other documents necessary to an effective credentialing process. |

|Ensures that medical staff meets all training requirements for MSC and provide necessary tools and instructions for training. |

|Data entry, maintenance and trending of QI indicators, and occurrence reports. |

|Coordinate and complete tracking information for ongoing continuous quality improvement studies related to CQI data: hospital transfers; surgical site wound infections,|

|and safety in-service training. |

|Maintain various MD Peer Review Spreadsheets – MS Service Study, Medical Audit and special reports as requested by Quality Manager |

|Utilize Epic (HealthLink/OpTime) software to develop methodologies for extracting data and designing reports to facilitate QI projects, i.e. chart audits, peer review |

|process. |

|Review, trend and report on MSC Hand Hygiene monthly compliance. |

|Collect and use measurement data daily/weekly/monthly to monitor the effectiveness of changes. |

|Supervise and facilitate both daily and monthly patient record audits. Ensure that all patient records are complete, including: Authenticate operative report, |

|pathology, laboratory, medical imaging records and miscellaneous documentation. |

|Help facilitate quality projects and preparation for routine compliance of set AAAHC guidelines. Review changing guidelines annually and make necessary changes for |

|compliance. |

|Assist in the facilitation of innovative patient-centered system design changes that push the boundaries of traditional thinking while maintain credibility and engaging|

|stakeholder support |

|Maintain quality record compliance with AAAHC guidelines and help facilitate preparations. |

|Guides teams in clarifying problems and identifying opportunities for improvement. Facilitates small to medium problem brainstorming sessions. |

|Understands how to analyze and research problem statements, establish team objectives, and research external and internal benchmark performance standards. Applies |

|appropriate process methodologies, tools and techniques in the facilitation of process design or re-design engagements. Helps to conduct basic root cause analysis on |

|problem statements. |

|Develop system documentation, workflows, policies and procedures related to assigned projects. |

|Maintain the integrity and PHI for patients and assist staff with related questions to HIPAA compliance. |

|Cross-train with associated positions with support staff to assist as needed in various facets. |

|Create a climate that produces positive staff motivation and productivity |

|Coordinate and complete daily posting of MSC cases in Optime system. Serve as liaison between MSC and UWMF/UWHC coders |

|Manage “Request for Release of Information” ensuring proper documentation to process request and in accordance with Wisconsin statutes. Maintains a log of all charts |

|and information released |

|Notifies appropriate security team members of newly credentialed providers at time of initial appointment. |

|Organizes and maintains credentialing files. |

|Attend and prepare minutes for other meetings as requested. Distribute appropriate agenda and materials prior to the scheduled meeting. |

|Prepare agendas, letters, memos, presentations and reports as directed. |

|Participate in team projects and develop tools to assist department function. |

|Complete job duties within deadlines and assigned hours. Be available to be flexible in daily work hours to meet the surgery centers schedule. |

|Attend staff meetings, educational and safety programs. |

|Adheres to MSC Pledge of Service Excellences and actions reflect respect for patients, families and all health team members. |

|Perform other duties and projects, as requested. |

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|ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS. |

|JOB REQUIREMENTS |

|Education |Minimum |High school diploma or equivalent |

| |Preferred |Bachelor’s degree in Business Administration, Public Health, Computer Science or related field |

|Work Experience |Minimum |3-5 years’ experience in health care environment |

| | |Include: medical receptionist, transcription, medical records) |

| |Preferred |1-2 years of credentialing experience |

| | |1-2 years of Quality Improvement experience |

| | |Working knowledge of health applications e.g. MSC software, Epic Systems, Crystal Reports, ECHO credentialing |

| | |software |

| | |Experience facilitating/leading teams |

|Licenses & Certifications |Minimum | |

| |Preferred | |

|Required Skills, Knowledge, and Abilities |Extensive knowledge of databases, including Microsoft Access |

| |Strong computer skills, as well as knowledge of and ability to use various types of computer software and |

| |database programs. Required: Microsoft Office, Word, Excel, and PowerPoint. |

| |Solid knowledge of medical/surgical terminology, anatomy, physiology and disease processes Ability to interact|

| |with and work around people |

| |Ability to identify medical documentation problems, understand the content of medical records and translate |

| |these needs into operational/quality support systems |

| |High degree of detail and accuracy |

| |Ability to work independently and interpret clinical content, disease processes as well as to effectively |

| |communicate with clinical management |

| |Ability to make judgments in demanding situations |

| |Ability to react to frequent changes in duties and volume of work |

| |Excellent oral and written communication skills, (including grammar and spelling) |

| |Ability to listen empathetically |

| |Ability to logically organize details |

| |Excellent prioritization and organizational skills |

| |Comfortable accepting responsibility for medium to large scale projects involving multiple resources and |

| |spanning many months from start to finish |

| |Ability to manage multiple concurrent activities |

| |Professional demeanor |

|AGE SPECIFIC COMPETENCY (Clinical jobs only) |

|Identify age-specific competencies for direct and indirect patient care providers who regularly assess, manage and treat patients. |

|Instructions: Indicate the age groups of patients served either by direct or indirect patient care by checking the appropriate boxes below. Next, |

| |Infants (Birth – 11 months) |X |Adolescent (13 – 19 years) |

| |Toddlers (1 – 3 years) |X |Young Adult (20 – 40 years) |

| |Preschool (4 – 5 years) |X |Middle Adult (41 – 65 years) |

| |School Age (6 – 12 years) |X |Older Adult (Over 65 years) |

|JOB FUNCTION |

|Review the employee’s job description and identify each essential function that is performed differently based on the age group of the patient. |

| |

|PHYSICAL REQUIREMENTS |

|Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations may be made available for individuals with |

|disabilities to perform the essential functions of this position. |

|Physical Demand Level |Occasional |Frequent |Constant |

| |Up to 33% of the time |34%-66% of the time |67%-100% of the time |

|X |Sedentary: Ability to lift up to 10 pounds maximum and occasionally |Up to 10# |Negligible |Negligible |

| |lifting and/or carrying such articles as dockets, ledgers and small | | | |

| |tools. Although a sedentary job is defined as one, which involves | | | |

| |sitting, a certain amount of walking and standing is often necessary | | | |

| |in carrying out job duties. Jobs are sedentary if walking and | | | |

| |standing are required only occasionally and other sedentary criteria | | | |

| |are met. | | | |

| |Light: Ability to lift up to 20 pounds maximum with frequent lifting |Up to 20# |Up to 10# or requires |Negligible or constant |

| |and/or carrying of objects weighing up to 10 pounds. Even though the | |significant walking or |push/pull of items of |

| |weight lifted may only be a negligible amount, a job is in this | |standing, or requires |negligible weight |

| |category when it requires walking or standing to a significant degree.| |pushing/pulling of arm/leg | |

| | | |controls | |

| |Medium: Ability to lift up to 50 pounds maximum with frequent |20-50# |10-25# |Negligible-10# |

| |lifting/and or carrying objects weighing up to 25 pounds. | | | |

| |Heavy: Ability to lift up to 100 pounds maximum with frequent lifting |50-100# |25-50# |10-20# |

| |and/or carrying objects weighing up to 50 pounds. | | | |

| |Very Heavy: Ability to lift over 100 pounds with frequent lifting |Over 100# |Over 50# |Over 20# |

| |and/or carrying objects weighing over 50 pounds. | | | |

|List any other physical requirements or bona fide occupational qualifications:| |

Work/Environmental: Moderate noise level consistent with an office environment

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