Provide consultation and support for facility wide quality/performance improvement and
payer program improvement processes 

Provide ongoing assessment of performance improvement projects, and assists in ensuring
successful clinical project implementation 

Has a good understanding of Quality Payment Programs, State Licensure/HCFA,
Conditions of Participation for the Hospital and CMS regulations 

Assess overall compliance, guide personnel in compliance with those standards and
preparation for accreditation surveys 

Data coordinator and resource person for internal and external projects 

Responsible for promoting and monitoring safe, high quality, cost effective health care

Continued employment and raises in this position are dependent upon Central Montana
Medical Center's fiscal viability and: •

Actions and communications that contribute to a team concept and create a
positive environment for all customers •

Acceptable performance of essential and all job duties •

Acceptable attendance record •

Accountability for safety to self, patients, visitors and all customers, and care of
equipment and building •

Adherence to departmental and facility policies and procedures, education
requirements, compliance monitoring and reporting, and CMMC Code of
Conduct •
Accountability for the consequences of own actions •

Physical and emotional ability to perform essential functions •

Acceptable background investigation results if required for position

Minimum Education, Experience, Licensure, Certification required:

• ASN required; BSN preferred
• Minimum of three years nursing experience with leadership experience preferred.
• Quality improvement experience preferred.

• Will have accredited QI Certification within 1 year of employment.

1 Receives reports and data related to Quality Improvement and analyzes for trending, patterns,
and submits reports as required

2 M a intains documentation and meets requirements for Quality/Performance Improvement.

3 Extracts and maintains quality improvement data and provides reports as requested or
needed.

4 Responsible for learning/maintaining current knowledge and requirements of the quality
programs.

5 Participates in performance improvement initiatives as it relates to quality improvement.

6 Develops and demonstrates effective communication tools to disseminate information and to
interact with department and organization’s staff.

7 Assist facility staff with proper documentation/requirements for quality requirements

8 Analyze quality improvement activities and identify opportunity trends for better patient health

outcomes.

9 Participates in meetings and events as required or requested.

10 Assists and serves as a resource to hospital, medical staff, and administration for Quality
Improvement issues as appropriate.

11 Other duties as assigned.

Knowledge, Skills, Abilities:

• Experience in working with an Electronic Health Record.
• Proficiency in database, spreadsheet, and word processing software applications essential.
• Demonstrates the ability to effectively communicate with all levels of hospital and practice-

standards/Conditions of Participation for the hospital standards as a guideline for quality
improvement.

• Ability to identify, define, and evaluate priority problems and suggests solutions

OCCUPATIONAL EPOSURE for this position:

Category I Direct contact with blood or other bodily fluid to which
universal precautions apply

Category II Activity performed without blood/bodily fluids exposure,
but exposure may occur in emergency

Category III Task/activity does not ordinarily entail predictable
exposure to blood/bodily fluids

OTHER EPOSURE for this position:

Radiation

Noise

Other (Specify)

PHYSICAL DEMANDS:
(Essential functions strength rating for position - see Job Analysis)

Sedentary Exert up to 10# occasionally or negligible force frequently

Light Exert up to 20# occasionally, < 10# frequently or
negligible force constantly

Medium Exert up to 50# occasionally, up to 25# or up to 10#
constantly

Heavy Exert up to 100# occasionally, up to 50# frequently or up
to 20# constantly

Very Heavy Exert > 100# occasionally, > 50# frequently or
> 20# constantly