MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor degree in health care related field

2. West Virginia state criminal background check, and Federal, if applicable, for DHHR BMS regulated area

EXPERIENCE:

1. Three years' experience in a clinical healthcare setting with at least one year of oncology and/or BMT experience; with emphasis on quality improvement process experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master's degree (Nursing, Public Health, Healthcare Administration)

EXPERIENCE:

1. One year of clinical chart review and abstraction

CORE DUTIES AND RESPONSIBILITIES:The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Educates staff and physicians throughout the system on regulatory /accrediting requirements to promote readiness and ongoing compliance.

2. Works with leadership to establish and maintain systems to review, modify, and approve all policies and procedures intended to monitor compliance with quality standards and/or the performance of the Quality Programs.

3. In collaboration with the Program Director and Department Leadership coordinates accreditation applications, the preparation, education, the site visit and response to the application results. Partners with all members of each team including inpatient and outpatient nursing, and physicians, and other departments to assure a cohesive and integrated accreditation process.

4. Interacts closely with each clinical programmatic team, to assure ongoing compliance with all standards of each accreditation and other quality measures identified by program leadership.

5. Assists with the investigation and tracking of errors and deviations and will propose and assist with the implementation of changes to processes and Standards of Practices (SOP) where indicated by evaluation of documented trends in errors and deviations.

6. Attend conferences, tumor boards, and other related meetings to ensure reliable data collection

7. Identify streamlining and process improvement opportunities in the data collection process.

8. Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the American College of Surgeons and QOPI database, NAPBC and for FACT Accreditation.

9. Utilize software applications for data collection and analysis.

10. Responsible for the accurate and timely entry of data into pertinent databases and meets caseload accrual requirement protocol.

11. Develops reports and other documents as requested by Cancer Service Line Leadership.

12. Establish effective working relationships with members of the hospital, especially staff in the BMT, surgical oncology, medical oncology, Gynecology/Oncology, nursing, health information management, quality outcomes, CTRU, and informatics.

13. Serve as an educational resource for oncology quality data and initiatives (i. e. American College of Surgeons, QOPI, FACT, NAPBC) for developing educational materials and delivering presentations.

14. Participates in required program teleconferences.

15. Participates in required education annually.

PHYSICAL REQUIREMENTS:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this position, the employee is required to walk and stand for long periods of time.

2. Must be able to lift 30 pounds and must be able to push 50 pounds

3. Dexterity required to finger, handle, and reach

WORKING ENVIRONMENT:The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Additional Job Description:

The main oversight for this position will be supporting the colorectal area and assisting in obtaining national accreditation. This individual will also support regional sites within the institute.

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