* Evaluate professional practice and peer review programs to ensure alignment with industry best practice and external evidence.

* Protect confidentiality of privileged information in accordance with applicable legal and regulatory requirements.

* Model non punitive and corrective action tenets/behaviors as part of the review processes.

* Manage performance measurement review process and criteria development for peer protected clinical review processes.

* Oversee Quality Outcomes RN efforts to assemble and provide informational resources that reflect the intent of the quality review outcome.

* Collaborate with NAH departmental stakeholders to enhance existing processes.

* Demonstrate knowledge of the impact of healthcare payment models as they apply to quality measurement and improvement programs.

* Analyze the appropriate utilization of healthcare services.

* Monitor the impact of value-based payment initiatives and quality report cards and forecast future organizational goal-setting and process improvement work.

* Demonstrate knowledge of care coordination resources and their impact upon value-based payment models.

* Define the need, expected benefits, and alignment of projects to the organizational mission, vision, values, strategic goals, and business priorities.

* Work with Quality RNs to ensure that PI/QI plans include an opportunity statement, goals, scope, timeline, and critical milestones utilizing project management methodologies, performance measurements, and tools.

* Manage the work defined in the project plan/charter/A3/scope document to ensure the project moves forward according to project goals and timelines.

* Track, monitor, and communicate project progress to all stakeholders and provide alerts to the project sponsor when deviations from the plan occur.

* Promote a culture of continuous improvement that leads to sustained results and optimal performance.

* Mentor the Quality RNs to effectively communicate the vision, expectations and results of PPI clearly consistently, and appropriately to stakeholders.

* Recommend meaningful measurement tools to prove the need for improvement, make changes, and measure return on investment.

* Identify and mitigate barriers that impede sustainable change.

* Implement accountability structures and controls required to deploy, monitor, and ensure compliance with the work changes required to achieve and sustain improved performance.

* Design data collection plans including measure selection, development, and sampling methodologies.

* Assist in evaluating and/or developing data management systems (e.g. databases, registries).

* Validate the structural integrity of data sets.

* Understand statistics concepts and accurately apply statistical methods to describe data.

* Fully understand the lessons of the data in light of relevant clinical and operational subject-matter expertise.

* Summarize complex findings through appropriate methods of data visualization.

* Transform a data-driven work product into a comprehensive narrative structure that tells the whole story of the analysis to a non-technical audience.

* Serve as subject matter expert and mentor for analytic design for Quality RN projects.

* Responsible for reporting any safety related incident in a timely fashion through the Midas/RDE tool; attends all safety related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

* Stays current and complies with state and federal regulations/statutes and company policies that impact the employees area of responsibility.

* If required for position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.

* Completes all company mandatory modules and required job specific training in the  specified time frame.