• Quality Improvement Specialist- RN

    WMCHealth (Poughkeepsie, NY)


    Quality Improvement Specialist- RN

     

    Company: MidHudson Regional Hospital

     

    City/State: Poughkeepsie, NY

     

    Category: Clerical/Administrative Support

     

    Department: Quality Mgmt Service

     

    Union: No

     

    Position: Full Time

     

    Hours: M-F 8a-4:30p

     

    Shift: Day

     

    Req #: 45071

     

    Posted Date: Oct 31, 2025

     

    Hiring Range: $86,638-108,908 annually

     

    External Applicant link (https://pm.healthcaresource.com/cs/wmc1/#/preApply/31004) Internal Applicant link

    Job Details:

    JOB SUMMARY To provide leadership, direction and assistance to the hospital and the medical staff to achieve the goals of the Performance Improvement (PI) Plan. Serves as a resource, an educator and a consultant. Ensures accurate data collection, analysis, and reporting to establish and maintain practice standards and organization-wide PI efforts. RESPONSIBILITIES Responsibilities related to medical staff PI

     

    + Screens cases to identify issues for physician review, using criteria established by the medical staff and the NYS DOH.

    + Initiates the peer review process by reviewing cases identified through the screening (mortalities, OR incidents, infections, etc.).

    + Documents findings in MIDAS within established time frames.

    + Identifies cases that present a serious concern (i.e. a possible sentinel event, an aberrant practice pattern, a potential lawsuit, etc.) and alerts the department director, medical staff leadership, and claims manager.

    + Conducts special studies in collaboration with medical staff on issues that are high-risk, high-volume, or problem-prone. This includes chart review, data collection, data analysis, and graphical display.

    Responsibilities related to risk management

    + Review incident reports on a daily basis.

    + Identifies incidents that present a serious concern (i.e. a possible sentinel event, an aberrant practice pattern, a potential lawsuit, etc.) and alerts the department director, administration, and the claims manager. Initiates a more thorough review to clarify the circumstances.

    + Creates MIDAS reports that will assist in the identification of patterns and trends.

    Responsibilities related to comparative performance

    + Reviews every case identified as meeting criteria for the core measures.

    + Identifies opportunities for improvement (OFI’s) and attempts to resolve them with the appropriate physician and/or staff. Initiates strategies for correction of OFI’s.

    + Ensures all physician-related OFI’s are in the respective quality profiles.

    + Verifies the integrity of the data prior to harvest.

    + Upon receipt of validation chart requests, re-reviews the selected medical records to identify any errors.

    + Achieves a score of at least 85% on the validation studies. NOTE: Passing is 80%. Score > 90%

    + Analyzes results of validation studies, identifying errors and opportunities for self-learning.

    Responsibilities related to organization-wide QI

    + Functions as a resource to other departments in support of their QI efforts. Serves as leader or consultant to a QI team.

    + Analyzes data from other sources, such as Treo, Hospital Compare, etc. to identify patterns/trends and areas for improvement. Assumes leadership responsibility for identified projects.

    + Supports on-site reviews by DOH surveyors, coordinating information, reviewing the medical record in question, and assisting the surveyor with all requests.

    + Serves as a member of the Quality Council and/or other appropriate hospital committees.

    + Assumes leadership for major projects, i.e. MIDAS manager.

    Other

    + Performs other related duties as assigned.

    QUALIFICATIONS/REQUIREMENTS EXPERIENCE

    + Minimum of five years experience in Med/Surg nursing.

    + Minimum of two years’ experience in quality improvement/risk management.

    EDUCATION

    + Graduation from an accredited school of nursing.

    + BSN preferred.

    LICENSES/CERTIFICATIONS Licensed in NYS as a Registered Professional Nurse OTHER

    + If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

    + Computer literacy, including word processing and data management.

    + Excellent oral and written communication skills.

    + Excellent interpersonal skills; ability to deal effectively with individuals and groups.

    + Initiative, creativity and flexibility.

    SPECIAL REQUIREMENTS N/A

    About Us:

    MidHudson Regional Hospital

     

    MidHudson Regional Hospital in Poughkeepsie, NY, is home to the mid-Hudson Valley’s most advanced healthcare services. This 243-bed facility cares for more than 10,000 inpatients annually while performing an additional 325,000 outpatient procedures each year. MidHudson Regional Hospital operates the area’s only Level II trauma center, is home to the Redl Center for Cancer Care and Center for Robotic Surgery, and is a destination hospital for patients with serious illnesses and injuries.

    Benefits:

    We offer a comprehensive compensation and benefits package that includes:

    + Health Insurance

    + Dental

    + Vision

    + Retirement Savings Plan

    + Flexible Savings Account

    + Paid Time Off

    + Holidays

    + Tuition Reimbursement

     

    External Applicant link (https://pm.healthcaresource.com/cs/wmc1/#/preApply/31004) Internal Applicant link

     

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