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Tri-City Medical Center
Oceanside, CA

Position Summary:

This position is responsible for monitoring all quality activities of the hospital in accordance with accreditation, regulatory and other requirements.  This position is responsible for timely/accurate collecting, submitting and reporting process and outcome data on patient populations as determined by hospital and departmental leadership. Some of which may include mandated clinical projects by CMS, The Joint Commission or other regulatory agencies. This position acts as a mentor and coaches staff to ensure quality outcomes and limit variability in performance. This position prepares dashboards and graphs to track and trend organizational metrics for quality improvement and internal/external reporting. This individual meets with quality leaders on a regular basis and participates in committees as assigned to improve practice and patient care.  Analyzes information and identifies key issues that meet the criteria and measures set forth from the Quality Assurance/Performance Improvement and Clinical Quality Committees. This position requires collaboration with nursing informatics and department educators to understand clinical workflow to improve outcomes/patient safety.  The individual should have comprehensive and advanced clinical knowledge, data analysis and performance improvement experience as well as strong organizational skills.

Major Position Responsibilities:

Retrospective/Concurrent Medical Record review/abstraction and vendor oversite.

Inter-Rater Reliability of abstracted measures.

Identify gaps and drive performance improvement with both eCQMs/CQMs.

Analyzes reports, identifies and communicates important findings, enters results into appropriate database. Thoroughly understands organization quality improvement initiatives as they relate to our regulatory reporting and reimbursement.

Communicates effectively with targeted staff and physicians to implement changes in documentation, clinical practice and behavior as indicated by results of medical record reviews.

Monitor need for updates in accordance with regulatory, accreditation changes and facility needs.

Develops and presents meaningful reports with analytical summary for departments, committees and staff.

Performs ad hoc audits, special studies, or other quality analysis activities and collaborates with organizational leaders to present analytical summary.

Applies, understands and follows Regulatory Reporting standards/guidelines, Hospital Rules and Regulations, Hospital Policies and Procedures, Title 22; Joint Commission Standards, Medicare Conditions of Participation.

Participates in other initiatives and programs and performs other duties as assigned by the Department Leader.

Responsible to maintain confidentiality of sensitive information.

Evaluates and presents information in a professional manner.

Safety and Infection Control Responsibilities

Responsible to maintain a safe and clean work environment, including unit based specific safety and infection control requirements.


Minimum 5 years of healthcare quality experience. Will consider 2 years of nursing/clinical coding with 2 years of healthcare quality experience, required.

Understanding of regulatory requirements, performance improvement methodology, required.

Ability to facilitate clinical groups to review performance improvement data and develop/implement specific actions resulting from the review of information.

Proven ability in organizing, analyzing, and synthesizing quantitative and qualitative data, required.

Ability to understand and apply Hospital Rules and Regulations, Hospital Policies and Procedures; Title 22; Joint Commission Standards; and Medicare Conditions of Participation, required.

Excellent oral and written communication and interpersonal skills, required.

Experience working with sensitive information and maintaining confidentiality, required.

Demonstrated knowledge of clinical applications, Word, Excel, PowerPoint, Outlook, required.

Proficiency in electronic medical record systems, required. “Cerner” electronic medical record system knowledge, preferred.

Strong computer database skills, preferred.

Ability to work effectively in a team environment, required.

Knowledge of regulatory and accreditation standards, required.

Ability to manage databases and retrieve, analyze, summarize, and present information effectively, required.



Graduate of an accredited school of nursing with a Bachelor’s in Nursing or Bachelor’s/Master’s Degree in a Healthcare related field, required.

Bachelor’s or Master’s degree in information systems or management, preferred.


CA RN License, preferred.


Certified Professional in Healthcare Quality (CPHQ) required or must obtain within 24 months from hire date, required.

EOE / Drug Free Workplace

Promoting healthcare quality professionals through education, resources, networking and leadership.

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