Job Description

Under general supervision, oversees and coordinates quality reporting and outcomes management of acute and chronic inpatient rehabilitation patients. Responsible for coordinating departmental quality improvement activities to ensure consistency with organization policies, procedures and philosophy, and to maintain and improve the quality of care given to the patient. Develops, implements, and documents activities relating to the Quality Assurance Program. Collects, and analyzes data, conducts presentations, provides consultation, and staffs hospital-wide committees.

Assumes the primary role for coordination of data and data integrity of the IRF-PAI in Uniform Data System (UDS). The coordinator collects, reviews and monitors the information contained in the IRF-PAI to ensure accuracy to clearly reflect the status of the patient and their care needs as documented in the medical record. Provides ongoing monitoring of program and patient outcomes as compared to state, regional and national benchmarking. Performs ongoing monitoring of trends or changes within our own facility outcomes data, working closely with the clinical program leadership

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by the person assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Responsible for coordination of data entry and data integrity of the IRF-PAI in Uniform Data System (UDS).
  • Using clinical judgement, coordinate the accurate completion of IRF-PAI data for submission to UDS. Works in collaboration with the clinical teams to ensure clinical data is accurate in the IRF-PAI and reflected in the electronic medical record. This includes identification and communication of errors to program leadership to support timely and ongoing education to staff.
  • Collaborates with the Program Medical Director and Program directors to ensure correct impairment group codes and acute inpatient rehabilitation diagnosis codes are assigned.
  • Helps ensure medical record integrity and compliance through medical record audits.
• Work closely with our Health Management Information Team to ensure that we are accurately coding
• Plans, organizes, and directs departmental quality improvement activities. Conducts departmental studies of identified problem areas in accordance with the Quality and Performance Improvement Plan.
  • Provides staff support to quality management committees by assembling data for review. Handles correspondence to/from committees by writing letters/memos to the appropriate person, department or committee informing them of the recommendation or actions to be taken. Receives correspondence from departments or committees and shares information with the Committee/department quality management physician.
  • Reviews data related to clinical care, in conjunction with the quality management committee, to determine committee agenda and identify areas requiring further information.
  • Prepares reports as required for medical staff, quality management committees and quality task forces to identify trends or patterns that present an opportunity to improve the quality of patient care provided.
  • Shares trends, patterns or issues identified during concurrent reviews, providing explanation and details regarding monthly quality assurance reports, and/or obtains medical records or additional information to be discussed.
  • Facilitates the clinical review and problem-solving processes through the use of quality improvement methodology and tools.
  • Coordinates special quality improvement projects and studies. Identifies resources needed, persons to be involved and the logistics of accomplishing the project. Participates in State and Federal Quality projects to obtain comparative data on quality indicators, to use in assessing how well the institution is doing in relation to others and compliance with The Joint Commission standards.
• Analyzes and assesses the important aspects of care (such as appropriateness of diagnosis, blood transfusions, indication for surgery, clinical pertinence of medical record documentation, complications, anesthesia care, infections, utilization issues, etc.) for specific patient populations which represent important clinical issues and reflect the strategic clinical direction of the organization. Identifies areas for improvement.
  • Works with the healthcare team to determine the quality of care provided to support compliance with The Joint Commission standard of multidisciplinary approach to quality improvement
  • Works with the healthcare team to determine the quality of care provided to support compliance with the Commission on Accreditation of Rehabilitation Facilities, of multidisciplinary approach to quality improvement
  • Identifies opportunities for improvement in the care provided.
• Facilitate the development of strategies and action plans to correct the improvement areas. Facilitates multidisciplinary teams to achieve improved quality care.
• Collects quality and risk management data on an ongoing basis such as unplanned readmissions, deaths, unplanned returns to the operating room, Maryland Hospital Association Quality Indicator Project Indicators, Clinical Quality Indicators for Board Report, occurrence screens.
  • Measures and assesses data using pre-determined, medical staff approved criteria to identify cases requiring peer review, identify causes for indicator rate outliers and to document trends or patterns that identify opportunities for improvement in the quality of care provided.
  • Provides feedback to multidisciplinary teams regarding patient outcomes and processes of care.
• Develops effective working relationships Risk Managers, Case Managers, and Department managers to assure cooperation and data sharing which results in improved patient care.
• Provides consultation to ancillary support and clinical departments within the Medical System to establish quality indicators, analyze quality and utilization data, identify trends/patterns and formulate plans for resolving issues/problems.
• Staffs organization-wide quality improvement committees and participates on process management teams.

Qualifications

** Education & Experience**

1. * Bachelor’s degree in Nursing or in Physical Therapy, Occupational Therapy, Speech Language Pathology **_or_** an equivalent combination of education and experience, is required.
   

* Current healthcare licensure in the State of Maryland is required.
* For nursing CRRN preferred
* Knowledge about IRF-PAI required
* Knowledge about The Joint Commission and Commission on Accreditation of Rehabilitation Facilities

** Knowledge, Skills and Abilities**

1. * Knowledge of quality improvement and risk management is required.
   

* Highly effective verbal and written communication skills are necessary to work with medical, nursing staff and external review agencies in monitoring and evaluating the quality of patient care.
* Ability to learn facilitation of clinical quality improvement and the problem-solving process in a clinical setting. Ability to learn quality improvement tools and methodology.
* Ability to assess utilization and quality management problems, recommend solutions, and resolve issues in a timely, efficient and effective manner.

** Patient Safety**

Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.

• Acts to correct observed risks to patient safety
• Reports adverse events and near misses to appropriate management authority
• Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation:
Pay Range: $40.61-$60.96
Other Compensation (if applicable): n/a
Review the 2025-2026 UMMS Benefits Guide

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