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Job ID: 36222
Location: Chapel Hill, NC
Facility/Division: UNC Medical Center
Status: Full Time
Shift: Day Job
Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.
This position is responsible for providing leadership to ensure validity of measurement, accuracy of data, patient safety and regulatory compliance with quality improvement, reporting, and regulatory initiatives. A clinical quality assurance specialist uses a combination of nursing, quality, and informatics knowledge to manage data, process, and information systems. In this role, the objectives would include improving clinical care as well as clinical documentation and reporting for treatment, prevention, and drug administration regimens, record keeping practices, workflow procedures, medical decision-making practices, and pay-for-performance programs.
1. Must be an active participant in staying current with all pay for performance programs, government regulations, and key health care system initiatives regarding medical record documentation and plan of care.
2. Performs medical record abstraction for the purpose of quality improvement or reporting. Review and analyze healthcare data and records, validating accuracy and quality documentation to ensure compliance with program requirements. Acts as primary resource and consultant for healthcare providers in regards to a complete and accurate medical record. Ensures that medical records meet regulations. Consults with healthcare provider or quality initiative team regarding missing documentation and ensures that the correct data is entered.
3. Presents results from data analysis to healthcare providers, chairs, appropriate boards, and quality initiative teams. Also presents at conferences, meetings, etc. on regulations and standards for documentation in medical records.
4. Promotes the improvement of patient care and clinical excellence in clinical information systems via effective collaboration with healthcare providers, business and quality analysts, and leaders of clinical programs and quality initiatives. Ensures that the health care system as an organization and clinical providers are following best practice care and are documenting in accordance with these clinical and quality initiatives.
5. Provides education to healthcare providers on best practice patient care as well as documentation, interpretation and compliance of the medical record. Collaborates with medical providers on the documentation for the elements of care for certain patient populations.
6. Works with quality initiative teams to improve care delivery and documentation. Provides support to develop and utilize processes that improve clinical documentation to support patient care, efficient clinical processes, and analytics needs.
● Bachelor's degree in Nursing (BSN) from a state-accredited school of professional nursing.
● Licensed to practice as a Registered Nurse in the state of North Carolina.
Professional Experience Requirements:
● Three (3) years of clinical experience in a healthcare setting or equivalent combination of education and experience.
Knowledge/Skills/and Abilities Requirements:
Legal Employer: STATE
Entity: UNC Medical Center
Organization Unit: OQE - Clinical Data Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Schedule: Day Job
Location of Job: US:NC:Chapel Hill
Exempt From Overtime: Exempt: Yes
This is a State position employed by UNC Health Care System.
The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.
UNC Health is an equal opportunity employer. As such, UNC Health offers equal employment opportunities to applicants and employees without regard to race, color, religion, sex, national origin, age, genetic information, disability, sexual orientation, gender identity or political affiliation.