CQI/RN Manager
Liberty Enterprises - Amsterdam, NY

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JOB TITLE: Continuous Quality Improvement Manager/RN Manager

DEPARTMENT: Continuous Quality Improvement Department / Medical Dept.

LOCATION: New Dimensions in Health Care

REPORTS TO: Director of the New Dimensions in Health Care and Facilities Management


Hours of Work :
Full time 37.5 hours per week.


Education and/or Experience:
Bachelor's Degree in Nursing or other Health Care field (i.e. Human Services) and/or equivalent experience. Minimum 3 years prior experience in a Quality Improvement related role in a hospital, regulatory agency or outpatient clinic setting involving medical services with a minimum of 3 years experience supervising in a quality improvement department. Registered Nurse with minimum 3 years experience as an RN Supervisor. Good communication skills required. Experience with electronic medical records a plus.

Physical Requirements:
Meets all pre-employment and annual health requirements of New Dimensions in Health Care


Facilitate the development and implementation of a written Quality Improvement Program that includes a planned and systematic process for monitoring and assessing the quality and appropriateness of patient care and clinical performance on an ongoing basis.

Establish review criteria in accordance with current standards of professional practice for monitoring and assessing patient care and clinical performance.

Conduct periodic medical record reviews for all disciplines and focused reviews as appropriate and as requested.

Communicate on an ongoing basis to the Medical Director, Continuous Quality Improvement Committee, and Directors any issues pertaining to quality occur.

Coordinate the Peer review process, which includes development of the process, ongoing evaluation and make changes as need dictates under the direction of the Medical Director and in compliance with the Department of Health.
Direct Supervision of the Licensed Practical Nurse assigned to the Medical Department , including other support staff when assigned to the medical department

Ensure the development, review, and revisions of Medical Clinical Protocols. Evaluate on an ongoing basis, the efficiency and coordination of clinical services from the perspective of meeting the clinical treatment needs of the patients seen in the Primary Medical and Medical Specialty clinics.

Coordinate and conduct periodic Policy and Guidelines Committee and facilitate the review, revision and updates to policies and guidelines according to agency/government regulation requirements.

Ensure compliance to track all staff Pre-employment and Annual Health requirements and report to the Director areas of concern.

Develop, implement and evaluate the Infection Control Program on an ongoing basis. Ensure assigned staff conducts infection control surveillance. Conduct ongoing committee meetings to discuss issues pertaining to Infection Control and that the Director is made aware of risks identified.

Coordinate the Appointment and Reappointment of Medical, Dental, Podiatry, and allied health practitioners with Clinical Privileges. This includes coordinating the ongoing Credentialing Committee, and discussions with the Medical Director on matters pertaining to the appointment and reappointment of these professionals.

Coordinate the Physician Profiling process to ensure data collected is communicated and reviewed at the time of reappointment and approval of clinical privileges.

Chair of Safety Committee, prepare and coordinate meeting agenda items. Coordinate the fire drills and disaster drills with Facilities Management staff. Consult with Liberty Safety Manager on current, revised, and new regulations.

Schedule and coordinate pre-employment and annual training for new and existing staff.

Prepare reports for all components of the CQI Program to facilitate the communication of CQI information to appropriate committees and the Board as requested by the Director.

Ensure that areas of risk identified through the CQI process are communicated to the Director and other appropriate staff as directed.

Ensure all incidents, such as staff injury accidents, unusual occurrences, medication events, and Patient Complaints are reviewed and action is taken as appropriate and that these events are reported to the CQI Committee and the Medical Director and Director.

Ensure the review of cases pertaining to quality and documentation issues are communicated to the Director and the Medical Director as appropriate and a peer review is conducted when requested by the Medical Director.

Review assigned web sites for the review of updated memorandums from the NYSDOH, OMIG, OIG, as well as Medicaid updates, and conduct research as requested on changes in rules and regulations.

Coordinate the onsite mandated consultant visits such as the Medical Record Consultant, Pharmacist, and Infection Control, as requested and ensure any areas of concerns are addressed as appropriate.

Coordinate patient satisfaction surveys and report results up to the CQI Committee, Directors, and Board.

Provide person centered attention to all patients

Manage daily operations in Medical Department including scheduling, triage, patient education and other patient care issues.

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