Registered Nurse - Performance Measures Coordinator

<p>The Central Texas VA Health Care System is recruiting for a Performance Measures Coordinator Registered Nurse position. The incumbent leads quality improvement and performance measurement initiatives, collects and analyzes data, monitors compliance with policies and standards, identifies trends, supports evidence-based practice, collaborates with interdisciplinary teams, and promotes continuous improvement in patient care and organizational performance.</p><h3>Major Duties</h3><p>The Performance Measures Coordinator is a fully developed position that executes continuous improvement responsibilities that demonstrate leadership, experience, and creative approaches to management of complex patient care. Facilitates the planning, monitoring, coordinating, and administrating recommendations for clinical and administrative Performance Measures (e.g. ORYX, Healthcare Effectiveness Data and Information Set (HEDIS), Patient Experiences, External Peer Review Program (EPRP), Electronic Quality Measures (eQM), Strategic Analytics for Learning and Improvement (SAIL). Provides direct support to Service Chiefs, Product Line Managers, and others in planning, designing, integrating, implementing, modifying, and evaluating the effectiveness of services to improve the performance measures and monitors. Provides real-time monitoring of all inpatients (acute, ICU, and surgical care) monitors and measures, Ambulatory Care (Primary Care, Specialty Care, Emergency Department), and Long Term / Residential Care (CLC, Domiciliary Programs). Actively functions as facilitator on Process Action Teams and Work Groups. Provides real-time, reliable, and accurate feedback and education to clinical leadership and clinical staff on findings of real-time monitoring. Reports performance measure issues to the leadership, Chief of Staff, and top-level management. Will be the facility's key person to help develop the medical center response in identifying performance measure improvement; identifies system problems and develops and implements appropriate interventions. Coordinates the EPRP activities including review of variances, analysis of results related to processes, and EPRP Exit Interviews. Possesses a thorough knowledge of the Office of Quality Performance (OQP) Measure Technical Manual. Provides education to all levels of the organization, especially to leadership, Service Chiefs, and champions on the performance measure process. Provides on-going education to clinical services and staff on the EPRP process, measures, and monitors outcomes at all CTVHCS sites. Coordinates and facilitates the Performance Measures Oversight Committee (PMOC). Supports and provides backup for the External Peer Review Program (EPRP). Support for EPRP includes attending and presenting on EPRP process, real-time monitoring, clinical dashboards, and outcomes at monthly Performance Measures Oversight Committee (PMOC) meetings and as needed in other meetings. Recommends champions for each performance measure and performance monitor, including supporting indicators. Disperses EPRP Data Accountability Checklists (DAC) to designated Service Chiefs and champions (e-mail encrypted or hard copies), on the EPRP process as soon as information is available to access on WVMI. Collects and organizes DAC appeals from Chiefs and champions prior to the EPRP exit. Coordinate with abstractor for review prior to the Exit Review date (minimum of one day prior). Submits the appeal spreadsheet to the ELB before the date of the EPRP Exit, if requested. Reviews EPRP Abstractor feedback with Chiefs and champions in order to conduct a second-level review of fallouts. Presents a preliminary DAC report to leadership upon request. Schedules and facilitates meetings between the EPRP Abstractor and Chiefs and champions as needed. Reviews potential appeals with VISN 17 Performance Measure staff prior to and immediately after EPRP Exit. Submits West Virginia Medical Institute(WVMI) and Office of Quality Performance(OQP) appeals immediately after evaluating feedback from VISN 17 Performance Measure staff. Proactively follows the appeal process and provides status and disposition updates to affected Chiefs and champions. Ensures the Abstractor has adequate technical and space resources prior to the arrival of the Abstractor. Performs other duties as directed. The Performance Measures Coordinator will provide an EPRP briefing at the morning report upon request. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Monday-Friday, 7:30 a.m. - 4:00 p.m. Telework: Position is eligible for Ad-Hoc Telework. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required</p><h3>Requirements</h3>U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement.<h3>Education</h3>The Associate Degree Nursing (ADN), Bachelor of Science degree in Nursing (BSN), or Master of Science degree in Nursing (MSN) must be fully accredited by the Accreditation Commission for Education in Nursing (ACEN) or the Commission On Collegiate Nursing Education (CCNE). Verification of accreditation may be obtained from http://www.acenursing.us/accreditedprograms/programsearch.htm or https://directory.ccnecommunity.org/reports/accprog.asp If your school has changed names, or is no longer in existence, you must provide this information in your application. If your school was accredited by ACEN or CCNE at the time of graduation, but is no longer listed on the websites, you must provide documentation of accreditation with your application packet. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.