Manages the regulatory and accreditation data collection and submission processes to ensure timely and accurate submission of data to agencies, as well as the dissemination of status and outcomes to appropriate internal stakeholders.  Monitors applicable CMS, Joint Commission and other applicable regulatory/accreditation data requirements and regulations, altering processes as necessary to maintain compliance.

Education:

• Bachelor’s degree in data science, business, healthcare administration, nursing or related discipline or ten years’ equivalent experience with Clinical Data Management required. Bachelor’s within 5 years of employment is strongly preferred.

Licensure/Certification/Registry:

• Completion of the MHS Lean Six Sigma Green Belt curriculum is required within 2 years of job placement.

Experience:

• Minimum five years of experience with clinical data as a system analyst, data abstractor, reporting analysis.  

Other Knowledge/Skills/Abilities:

• Knowledge of the federal (CMS/Medicare), state (IDPH/Medicaid) and Joint Commission quality programs required. Knowledge of other regulatory and or accrediting programs such as Magnet, Trauma Quality Improvement Program (TQIP), American Heart Association’s Get With The Guidelines (Stroke), American Burn Association Registry, or other regulatory and/or accreditation registries preferred.
• Expertise with working with ICD-10 DX, DRG & PCS is required.
• Expertise with healthcare comparative databases (Premier, Advisory Board) is strongly preferred.
• Experience working with CMS’s QualityNet is preferred.
• Ability to communicate with system and senior leadership regarding outcomes and status of registry and accreditation data submissions.
• Ability to manage staff assignments to ensure accurate and timely submission of data for each registry.
• Ability to execute projects from start to finish including the development, measurement and reporting of key performance indicators and commitment to continuous quality improvement required.
• Expertise with coaching and managing multiple clinical and/or technical staff.

1. Manages data abstractor personnel, including coordinating training, conducting performance reviews, counseling and discipline.

2. Manages the timely extraction, validation and submission of assigned regulatory metrics to the various regulatory and credentialing bodies.

3. Monitors changes to CMS and Joint Commission standards that affect quality measurement reporting for the health system.

4. Communicate data submission status and applicable outcomes to system and senior leadership.

5. Manage staff assignments to ensure accurate and timely submission of data for each registry.

6. Management of projects, including the development of the plan and reporting out on the project’s progress.

7. Expertise with coaching and managing multiple clinical and/or technical staff.

8. Validates and coordinates regulatory and/or registry data submission, and prepares and delivers critical communications with system leadership.

9. Collects information from diverse sources and performs various analyses and summations of the information and data.

10. Work with stakeholders to develop and manage dashboards for internal stakeholders.

11. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.