Core Measures​/Sepsis Coordinator

Registered nurse knowledgeable of the core measures, CMS requirements and best practices. Requires verbal ability to discuss program with the Medical Staff and Hospital Staff. Requires knowledge of preparing reports and numerical ability in order to evaluate the statistical data as well as making computation of department operations. Must be self‑motivated and have the ability to work independently on many occasions.

• 3 – 5 years in Nursing
• Preference in Critical Care
• Current Georgia RN License

Samples In‑Patient and Out‑Patient data monthly through Press Ganey.

Uploads weekly In‑Patient and Out‑Patient data via Press Ganey.

Reports medical record abstraction results externally to: CMS and The Joint Commission.

Internally to:
Quality, MEC, and Joint Commission Committees.

Also, to other departments as requested.

Reports data to agencies timely to meet various requirement dates (i.e. Chart Abstracted Measures, Electronic Clinical Quality Measures (eCQMs)).

Documents any case failures, monthly, after abstraction. Sends results to VP of Quality monthly.

Employee in this position will work on average 40 hours per week or greater. Can be asked to assist within clinical competency loyee will be expected to attend meetings scheduled before and after normal business hours and some weekends.

Sitting, walking and standing; lifting objects up to 20lbs. Visual and hearing acuity necessary.

Working with or near chemicals; working near radiation sources; working near fumes; working with hazardous waste; wearing protective clothing and/or equipment; exposure to blood‑borne pathogens.

Maintains Emergency Department and Hospitalists’ Physician Sepsis profiles. Reports to MEC monthly;
Physicians quarterly. Implements any recommendations from MEC.

Maintains Core Measures and Sepsis data on the Core Measures Dashboard and Maintains Maternal Infant Unit (MIU) Department data on the MIU Dashboard and updates monthly.

Performs Colonoscopy review monthly: 10‑year documentation and 7‑day post‑procedure visit to ER. Sends results to VP of Quality monthly.

Assesses Newborn Complications monthly for any Severe/Moderate Complication failures. If any, investigates further and does case write‑up. Sends results to VP of Quality monthly. Sends Perinatal Measures results report to MIU Director monthly for follow‑up. Compares MIU patient list with PNC measure information monthly. Any discrepancies are addressed.

Sends Hospitalists data to Hospitalists Manager quarterly and as needed.

Submits validation data as requested by CMS.

Schedules and participates in monthly Sepsis Task Force meetings. Formulates and presents monthly Sepsis Opportunity for Improvement Drill‑Down spreadsheet to the Sepsis Task Force. Provides Sepsis education monthly. Participates in Sepsis Community Coalition through GHA and Alliant Health. Updates Sepsis General and Nursing Orientation as requested by Educational Services. Submits monthly EMS Sepsis (Meditech #636) Report to the EMS Director.

Identifies opportunities for improvement and addresses these with appropriate personnel. Notifies physicians and staff of changes in measure criteria or opportunities for improvement.

Maintains a rapport and close working relationship with vendor, Press Ganey (PG) and PG consultant.

Completes Press Ganey Facility Profile annually.

Participates in hospital safety programs. Participates in planning changes and improvements.

Maintains all education requirements according to organization and state requirements.

Maintains rapport with staff and physicians. Maintains confidentiality. Displays professionalism through work and telephone etiquette, proper attire, and Standards of Performance.

Annual completion of World Health Organization hand hygiene education and training and its relationship to infection control in addition to physical demonstration and understanding of compliance monitoring.

Equal Opportunity Employer
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