RN Quality Management

Requisition ID
Employment Type
Full Time
Hours / Pay Period
Standard Hours
Monday - Friday (8:00 AM - 5:00 PM)
Facility / Process Level : Name
CHI St Joseph Health


CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. & from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.


Coordinates accreditation regulatory affairs and patient safety initiative for St. Joseph Physician Associates with entity leadership and staff to ensure compliance with mandated regulatory and accreditation standards and to improve patient safety.  Assume responsibility to review and monitor documentation in patient records to ensure quality of care and compliance.


  • Review patient charts and on-going patient documentation to ensure correctness and that the documentation is reflective of the appropriate assessment, as requested.
  • Works with physician leaders and administration leaders to assist in leading the quality committee and other quality initiatives as requested.
  • Works closely with managers on education and coaching of clinical team.
  • Assists with OPPE and FPPE for all St. Joseph Medical Group providers.
  • Assists with Peer Review for physicians.
  • Assess compliance with clinical accrediting and regulatory standards in collaboration with leadership, directors, office managers, staff and subject matter experts to identify areas of vulnerability and develop strategies to enhance compliance.
  • Participate in the development of appropriate documentation, clinical standards and indicators for quality measures as requested.
  • Monitors the IRIS event reporting system, notifies directors of events and identifies system wide issues.
  • Investigates patient safety issues and leads/coordinates Root Cause Analysis as indicated.
  • Oversight of Monthly Clinical Pertinence Reviews.
  • Oversight of clinical quality dashboard, reports, training and functionality.
  • Collaborate with IT and analytic staff to facilitate design and development of EMR functionality and analytics to support quality initiatives and patient safety compliance.
  • Educate providers and appropriate staff on the clinical quality measures and documentation standards.
  • Actively participates in performance improvement activities as requested.
  • Performs other duties as assigned to meet the organization`s needs.


Education and Licensure/Certifications

  • Required: RN License
  • Preferred: Bachelor's Degree Major in Nursing



  • Required: minimum of 5 years of clinical experience.

Knowledge, Skills, and Abilities:

  • Required: Demonstrated knowledge of Clinical Compliance, Best Practices, Medical Records Review and Legal aspects of Documentation.



Disclosure Statement:

The above statements reflect the general details considered necessary to describe the essential functions of the job as identified, and shall not be considered a detailed description of all work requirements that may be inherent in position.


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