Quality Improvement & Outcomes Coordinator

Company Description

We’re making Maryland stronger!

With roots that go as far back as 1895, the UM Rehab & Ortho Institute continues to be a pioneer in orthopedics and neurological disorders. From bones to brains, our cutting-edge hospital heals even the most serious of injuries, specializing in everything from total joint replacement to spinal cord injuries and neurological condition.  In total, our 141-bed facility welcomes over 3,000 patients every year. As the state’s largest provider of inpatient rehabilitation services, we offer some of the most advanced therapies for stroke, spinal cord injury, traumatic brain injury, orthopedic and sports injury, among many others.

Job Description

Under general supervision, oversees and coordinates quality reporting and outcomes management of acute and chronic inpatient rehabilitation patients. Responsible for coordinating departmental quality improvement activities to ensure consistency with organization policies, procedures and philosophy, and to maintain and improve the quality of care given to the patient.  Develops, implements, and documents activities relating to the Quality Assurance Program.  Collects, and analyzes data, conducts presentations, provides consultation, and staffs hospital-wide committees. 

Assumes the primary role for coordination of data and data integrity of the IRF-PAI in Uniform Data System (UDS). The coordinator collects, reviews and monitors the information contained in the IRF-PAI to ensure accuracy to clearly reflect the status of the patient and their care needs as documented in the medical record. Provides ongoing monitoring of program and patient outcomes as compared to state, regional and national benchmarking. Performs ongoing monitoring of trends or changes within our own facility outcomes data, working closely with the clinical program leadership

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by the person assigned to this classification.  They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Responsible for coordination of data entry and data integrity of the IRF-PAI in Uniform Data System (UDS). 
  • Using clinical judgement, coordinate the accurate completion of IRF-PAI data for submission to   UDS. Works in collaboration with the clinical teams to ensure clinical data is accurate in the IRF-PAI and reflected in the electronic medical record. This includes identification and communication of errors to program leadership to support timely and ongoing education to staff. 
  • Collaborates with the Program Medical Director and Program directors to ensure correct impairment group codes and acute inpatient rehabilitation diagnosis codes are assigned.
  • Helps ensure medical record integrity and compliance through medical record audits. 
• Work closely with our Health Management Information Team to ensure that we are accurately coding
• Plans, organizes, and directs departmental quality improvement activities.  Conducts departmental studies of identified problem areas in accordance with the Quality and Performance Improvement Plan.
  • Provides staff support to quality management committees by assembling data for review. Handles correspondence to/from committees by writing letters/memos to the appropriate person, department or committee informing them of the recommendation or actions to be taken.  Receives correspondence from departments or committees and shares information with the Committee/department quality management physician.
  • Reviews data related to clinical care, in conjunction with the quality management committee, to determine committee agenda and identify areas requiring further information.
  •  Prepares reports as required for medical staff, quality management committees and quality task forces to identify trends or patterns that present an opportunity to improve the quality of patient care provided.
  • Shares trends, patterns or issues identified during concurrent reviews, providing explanation and details regarding monthly quality assurance reports, and/or obtains medical records or additional information to be discussed.
  • Facilitates the clinical review and problem-solving processes through the use of quality improvement methodology and tools. 
  • Coordinates special quality improvement projects and studies.  Identifies resources needed, persons to be involved and the logistics of accomplishing the project.  Participates in State and Federal Quality projects to obtain comparative data on quality indicators, to use in assessing how well the institution is doing in relation to others and compliance with The Joint Commission standards.
• Analyzes and assesses the important aspects of care (such as appropriateness of diagnosis,