Career Opportunities

Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Quality Improvement Data Manager / Joint Commission Survey Coordinator is responsible for ensuring that all regulatory compliance criteria, deadlines, and reporting requirements are consistently met. This role oversees the integrity and management of clinical indicator databases and is accountable for both internal and external data reporting, including CMS Pay-for-Reporting, Value-Based Purchasing, and The Joint Commission (TJC) core measures. Proficiency in basic biostatistical analysis is essential to assess performance trends and support quality improvement initiatives. The position requires the identification and correction of data inaccuracies, timely submissions, and the provision of analytical support for all quality and pay-for-performance projects. The individual in this role works closely with Information Technology to develop and maintain robust databases and data extraction processes, while maintaining strict confidentiality with sensitive information. A critical component of this role is ensuring continuous readiness for regulatory surveys and managing all aspects of accreditation and re-accreditation processes to comply with CMS, TJC, and Department of Public Health (DPH) standards. Additionally, the role involves coordinating the collection, analysis, and submission of outcome and publicly reported data, including but not limited to ORYX, CMS-VBP, Patient Safety Organization (PSO) metrics, Meaningful Use, DPH reports, HCAHPS, and NDNQI.

Job Description:

Duties & Responsibilities:

• Assists the senior Director in the strategic planning, organizing and daily supervision of the quality improvement activities.

• Complete required administrative responsibilities, including annual budget plan, Kronos.

• Establish timelines and priorities for projects; coordinate action plans; and monitor results that are consistent with the overall strategic goals and imperatives

• This position will also lead accreditation and re-accreditation activities to ensure compliance with relevant standards of performance, including CMS, the Joint Commission, DPH.

• Is responsible for TJC Pre and Post survey activities (Application, ESC, MOS, etc.) Leapfrog survey coordination and submission, Pay for Performance submissions, External Data submissions (core measures, Mass Health, stroke GWTG, NDNQI, BCBSMA, HPHC etc..

• Supports and maintains compliance with regulatory and professional standards.

• Supports hospital leadership in the development of department/service Scorecards/dashboards.

• Serves as a professional role model and mentor to staff.

• Evaluate performance through the development/maintenance of statistical processes, control charts and databases

• Analyzes data for patterns or trends and opportunities to improve performance/ processes. 

• Provides statistical analysis education for PI teams and staff. Identifies trends through data analysis. Recommends strategies for improvement of patient care.

• Creates reports and provides database statistical reports and information as requested.

• Works collaboratively with the clinical managers, physicians, senior management, and Quality Improvement Specialists on coordinating and evaluating assigned quality improvement initiatives.

• Actively participates in the annual performance evaluation process of Quality Improvement Specialist and provides feedback to the Peer review and Quality Improvement Manager.

• Serves as the Administrator and primary resource for Q-Net including informational updates, reports, IPPS and OPPS requirements, PQRS requirements etc... and communicates all information and recommendations to appropriate leadership.

• Manages quality research projects as assigned including:  planning, organizing and distributing assignments to others; developing procedures for data collection, verification and management; overseeing the writing of interpretive reports based on statistical analysis of data collected.

• Ensure completion of, the Quality Scorecard, and the “Bog Dot” Dashboard and all analysis reports in support of P4P metrics on a monthly basis.

• Quality Data System (Datavision & UHC)Implementation:

  • Acts as project manager

  • Ensures the effective use of departmental information system by providing initial training for new users and training departmental staff of system upgrades, changes and new functions as necessary

  • Manages the implementation phase of the clinical information system

  • Collaborates with the Peer Review and Quality Improvement Manager to design and implement user training programs.

• Analyzes needs of the end-users and Outcomes Management Department to assure completeness of data requests.

• Develops education programs for nursing staff for quality measure compliance.

• Designs and develops data collection strategies, to include aggregation, analysis and reporting of confidential patient information to ensure data integrity and enhance information value.

• Coordinates all activities for TeamSTEPPS, Culture of safety assessment, Leadership Walkrounds

• Implement a service excellence program and monitor progress via HCAHPS scores.

Experience/Knowledge/Skills:

• Minimum of 5 years of experience in a healthcare organization working with CMS and The Joint Commission core measure data sets and progressive supervisory experience.

• Ability to utilize computer technology within multiple data software programs including proficiency in spreadsheets/databases and data analysis. Proficient with Windows based environment and electronic medical record.

• Excellent organizational skills with attention to detail, ability to prioritize heavy workloads, track and meet multiple deadlines, handle multiple tasks simultaneously. 

• Ability to utilize advanced computer technology within multiple data software programs (e.g. Meditech, MIDAS+ DataVision, Excel-QI Macros, Word, PowerPoint, Access) in addition, prepare reports in final format for review by the Senior Director of Quality and Safety.

• Excellent communication skills (written and verbal)

• Excellent analytical, organizational, problem solving and presentation skills.

Education and Experience:

• BS in Nursing or Healthcare field required. Master’s degree preferred

• Current R.N. license in Massachusetts preferred

• Certified Professional Healthcare Quality (CPHQ), preferred

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled