Surgery Clin Qual Measure Spec

Company: Mercy ( Learn More )

General Information
4 Year Degree
5 to 7 years
Not Specified
Job Description Overview:

We’re a Little Different

Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service.  

We don’t believe in jobs at Mercy, we believe in careers that match the unique gifts of unique individuals; careers that not only make the most of your skills and talents, but also your heart.

At Mercy, you’ll feel our supportive community every step of your day, especially the tough ones. We’re a team and love working that way. That team is expanding, and we currently have exceptional opportunities to help our communities grow.



Data Management:

  • Reviews and abstracts clinical data elements as required for the timely and accurate submission of ACS NSQIP.
  • Collects preoperative, operative, and postoperative data components for the program through the effective utilization of the hospital medical record systems.
  • Identifies surgical patients for inclusion in the program through the application of program inclusion/exclusion criteria and protocols.
  • Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the Program.
  • Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program through Inter-Rater Reliability (IRR) testing
  • Reviews weekly site accrual report on the database and responds to accrual report alerts.
  • Identifies streamlining and process improvement opportunities in the data collection process.
  • Measurement and Reporting:

  • Identifies significant data trends, values, or unusual data for additional review
  • Prepares reports that summarize QI data; analyzes data, identifies patterns and trends
  • Prepares and provides reports of case specific and aggregate measure data
  • Develops and monitors metrics to evaluate progress and build plans for continuous improvement.
  • Clinical Liaison:

  • Serves as educational resource on ACS NSQIP guidelines, criteria and required documentation by developing educational material and delivering presentations
  • Works collaboratively with community leaders in developing strategies and initiatives to help improve compliance with ACS NSQIP
  • Contacts patients and/or families via telephone and/or written communications postoperatively for the purpose of identifying possible occurrences associated with surgical procedures performed at the hospital.
  • NSQIP Participation:

  • Successful complete ACS NSQIP Training/Certification Program and maintain ongoing certification
  • Participate in program teleconferences
  • Attend national conference when budgeted
  • Qualifications:

    Each career at Mercy represents unique members of our caring ministry’s “body”, working together for the health and strength of the whole. To achieve our goals, we need all the parts functioning at their best and this requires the specific qualifications that you’ll bring with you:


  • BA/BS in relevant field or ADN
  • Ability to complete all pre-training, on-site training, and post-training
  • modules and pass the training post test for ACS NSQIP
  • Experience:

  • 5-7 years of healthcare experience
  • One year experience in hospital surgery department, surgery clinic, clinical research or medical records.
  • Clinical chart review and abstraction experience required.
  • Certification/Registration:

  • Successfully complete the ACS NSQIP SCR
  • Training/Certification Program
  • Other skills & knowledge:

    (skills, knowledge, abilities)

  • Must be analytical, resourceful, and possess excellent problem solving
  • Strong project management skills
  • Computer, Electronic Health Record and Internet experience.
  • Familiarity and comfort with MS Office products is essential for success in this position. (Word and Excel-required; PowerPoint and Access-preferred)
  • Ability to work as a team player with excellent communication skills

    Education:  Clinician preferred

    Experience:  Experience in leading efforts associated with reporting of quality measures to regulatory/accrediting organizations.

    Other skills & knowledge:  Basic statistical knowledge

    We’ll Support You at Work and Home

    Our foundations are built on dignity and respect. Modern Healthcare Magazine named us as a “top 100 places to work.” We go out of our way to help people feel welcomed. We offer day-one comprehensive health, vision and dental coverage, PTO, and employer-matched retirement funds, even to part-time employees. We’re proud to provide tuition reimbursement to help you grow and learn new skills.

    What Makes a Good Match for Mercy

    Compassion and professionalism go hand-in-hand with us, along with exceptional quality care. Having a positive outlook and a strong sense of advocacy is in perfect step with our mission and vision. We’re also collaborative and are not afraid to do a little extra to deliver excellent care – that’s just part of our commitment. If that sounds like a fit for you as well, we encourage you to apply.


    Job Requirements