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Responsible for fulfilling organizational needs related to Core Measure management and subspecialty data registry management.    Oversee day to day activities of data coordinators related to data abstraction, data entry and submission.  Ensures compliance with policies, quality standards, Joint Commission standards, CMS Conditions of Participation, and State regulations and codes.  Ensures organizational compliance with core measures and other performance indicators required by regulatory and accrediting entities.  Provides input into establishing goals, objectives and performance standards for the department.  Coordinates performance improvement initiatives with physicians and quality improvement teams and leverages data captured in registries and by Core Measures to measure process and outcomes.  Possesses leadership and knowledge to manage multiple individuals, systems, responsibilities and activities with close attention to detail.

1. Principal Responsibilities and Tasks

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

1. Supervises and serves as a clinical resource for registry team members, throughout the various abstraction and implementation support phases to ensure effective and efficient departmental functions. Registry and Core Measure team members include, but are not limited to, the following:
   1. Clinical Registry Coordinators
   2. Core Measure Coordinators
   3. Data Coordinators
   4. Health Care Analysts

1. Provides leadership for activities related to Joint Commission, CMS and MHCC chart-abstracted core measures and e-measures

1. Assures the staff appropriately applies the abstraction guidelines for the Core Measures, e-measures and other externally reported quality measures
2. Assures data quality, reliability, validity and timely submission of the data to TJC and CMS
3. Analyzes data to identify opportunities for improving organizations’ performance and improving staff abstraction capabilities
4. Provides oversight for staff education with on-going changes in documentation requirements as it relates to core measures and e-measures

1. Utilize performance management systems and databases, including
   1. Use of performance management system database (CMC) to validate data, produce reports. 
   2. Navigation of QNET to retrieve and/or input data, information and reports as it relates to Core Measures
   3. Navigation of external databases that publicly report core measures data

1. In collaboration with Hospital Leadership, hires and trains new staff members, conducts performance evaluations and manages disciplinary issues.  Provides input on staffing issues and developmental needs for the departments. 

1. Conducts new employee orientation and training as needed.
2. Monitor Kronos time records of direct reports and initiates corrective action as required.
3. Reviews work of staff to ensure work is completed accurately and resolves complex issues as required.

1. Reviews various forms of medical records for clinical data abstraction, abstracts pertinent clinical information via data entry and/or document scanning, into the electronic medical record, effectively using a variety of software packages and hardware devices.

1. Communicates with leadership, either verbally or through written methodology, to validate observations and identify strategies for sustained work process changes that facilitate complete, accurate clinical data abstraction and subsequent plans for optimization.

1. Conducts audits of abstracted information on a regular basis for quality assurance purposes and reports findings to leadership and physician champions as necessary; addresses individual needs for improvement with staff by implementing necessary performance improvement measures.

1. Participates in data collection as needed and coordinates and verifies data collected by other members of the registry team, including but not limited to:
   1. Performs data checks to assess quality of data submitted.
   2. Initiates and maintains required clinical and regulatory files.

1. Collaborates with multidisciplinary teams to achieve quality care delivery by providing outcome reports and other data as requested

1. Manage registry contracts and annual fees, including but not limited to:
   1. Ensuring contracts, data use agreements and business associate agreements (BAA) are reviewed and signed according to UMMS current legal and regulatory standards
   2. Ensure registry fees are paid in accordance with current “Accounts Payable” processes
   3. Maintain copies of current contacts, agreements, legal documents and proof of payment

1. Participates in conferences, departmental meetings, and continuing education offerings as applicable.

10.   Provides consultation to ancillary support and clinical departments on matters of research and quality improvement.

1. Education and Experience

1. 1. Bachelor’s degree in Nursing, Health related field, required; Master’s degree preferred. 

1. 1. Licensure by the Maryland State Board of Nursing Examiners is required  

1. 1. Three (3) years related experience in a clinical environment or clinical registry environment required; previous managerial experience preferred  

1. 1. Experience may be substituted for the educational requirement on a year-for-year basis for up to four (4) years.

IV.         Knowledge, Skills and Abilities

1. Highly effective verbal and written communication skills are required to develop relationships necessary to influence query processes: must be able to follow both verbal and written instructions, clarify/ verify data discrepancies and communicate with differing clinical personnel in an effective manner.

1. Must possess analytical skills necessary to clinically assess medical records as necessary to complete data abstraction.

1. Excellent organization and problem-solving skills and team leadership skills are required to develop and implement efficient work processes.

1. Ability to work within a changing environment and interact effectively with staff.

1. Ability to work under pressure and meet unexpected deadlines.

1. Ability to navigate/utilize varied hospital informational systems.

1. Ability to understand and utilize scientific/medical terminology and research theory in both oral and written communications.

1. Knowledge of best practice in Clinical Research. 

1. Ability to communicate efficiently and effectively both orally and in writing with a variety of people both internally and externally.

1. Ability to continuously seek to improve the quality of services and processes.

1. Knowledge of relevant PC applications.

VI.         Patient Safety

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

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

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