Lone Star Circle of Care

  • Quality Department Nurse (Georgetown)

    Job Locations US-TX-Georgetown
    Posted Date 3 weeks ago(7/26/2018 1:51 PM)
    # of Openings
    Nursing (LVN/RN)
  • Overview

    The Quality Department Nurse supports and assists the Quality Department in multiple aspects of quality-driven initiatives, data tracking and trend reports specifically related to vaccines, audits, and infection prevention and control (IPIC). Participates in planning, organizing, and follow through of Lone Star Circle of Care's vaccine, audit, and IPIC activities to ensure compliance with corporate, federal, state and local laws/regulations as well as regulatory and payer entities.


    General Duties:


    • Assists in facilitating data collection, tracking and trending of clinical quality improvement activities in the simplest, most efficient manner.
    • Uses discretion to report matters of significance to the Chief Medical Officer/Chief Quality Officer (CMO/CQO) and Associate Director of Nursing, Quality and Regulatory (ADNQR)or other relevant parties.
    • Demonstrates excellent customer service skills required for extensive interface with providers, staff and clients, including persons from diverse cultures and medically underserved populations.
    • Attends required meetings and participates in system wide councils or committees as requested, offers support and suggestions for ongoing Q/QA activities.
    • Maintain working knowledge of requirements of The Joint Commission (TJC), Texas Health Steps (THS), Department of State and Human Services (DSHS)-related programs, Health Resources and Services Administration (HRSA) and Bureau of Primary Health Care (BPHC), etc., as related to job duties.
    • Participates in performance improvement activities, as assigned, including clinical and environment of care (EOC) tracer activities on an assigned basis.
    • Works well under, and meets, deadlines, ensuring timely flow of information to, from and within the Quality Department.
    • All other duties as assigned.


    Vaccine Duties:


    • Maintain competency and education related to vaccines, vaccine storage and handling, administration and immunization schedules.
    • Works closely with Clinic Site Managers/Vaccine Coordinators on all aspects of vaccine management.
    • Ensures compliance with all regulations related to vaccine management.
    • Provides vaccine and vaccine audit related education to staff in person and via the learning management system (LMS).
    • Communicate and work with the CMO/CQO and ADNQR to implement or provide immunization support deemed necessary.
    • Maintain a contact relationship with the Department of State Health Services (DSHS) Regional Vaccine Coordinators for associated regions.
    • Collaborates with the Director of Pharmacy, CMO/CQO, and ADNQR to assess need and order annual flu vaccine.
    • Assists with completion of new and annual site applications for Texas Vaccines for Children (TVFC) and Adult Safety Net (ASN) programs, hereafter noted as State Vaccines.
    • Prepares, completes, maintains, and submits reports on State and Private Vaccines.
    • Ensures that the clinic sites and NextGen IT staff have the current VIS for each vaccine.
    • Attend State/Regional trainings to support the vaccine program.


    Audit Duties:


    • Achieves and maintains competence in NextGen in order to accurately abstract data for audits.
    • Maintains competence in NextGen medical records functions and compliance with HIPAA rules and regulations.
    • In coordination with the Custodian of Records, works with third party payers on patient medical record audits.
    • Maintains a working knowledge of documentation requirements for various programs including Texas Health Steps (THS) and other DSHS programs.
    • Performs documentation audits including, but not limited to, Critical Results Read Back (CRRB) and DSHS Programs including, but not limited to, THS, Abuse Reporting, and Family Planning/Texas Healthy Women (DSHS programs) on an established, recurring schedule.
    • Prepares, completes, maintains, and submits reports on audit activities as requested.


    IPC Duties:


    • Assist staff and management in the determination of reliable, valid, and measurable quality and patient safety indicators as related to IPIC.
    • Assists in monitoring data and trends related to IPIC.
    • Assists in ensuring cost effective, technology-based access to current information on IPIC and epidemiology including appropriate data collection and action plans.
    • Assists in the ongoing compliance with regulatory and accreditation requirements and best practices related to communicable disease management.
    • Collaborate with appropriate state and local health departments for reporting, surveillance, and follow-up of communicable diseases and related conditions.
    • Performs appropriate follow-up of communicable disease exposures in the clinical setting.
    • Monitors blood borne pathogen and infection control practices and prepare appropriate reports.
    • Provide staff training and education as related to IPIC.
    • Assists in new hire and annual health screens and immunizations.
    • Assists in coordinating the annual influenza immunization program.
    • During influenza season, tracks (organizational) flu, and flu like illnesses, and submits to the appropriate personnel or committee and DSHS as required.
    • Assists in the completion of all required annual and periodic reporting.




    • Staff Members and Directors shall deal with patients, providers, colleagues, and other internal and external LSCC contacts honestly, professionally and with empathy, following the principles of AIDET (Skill at a Glance) and the Language of Caring Overview (Staff). Staff Members and Directors shall demonstrate honesty and integrity in all LSCC business activities and work scheduling
    • Following the principles of AIDET and Language of Caring, Staff Members and Directors are expected to treat one another with respect and courtesy, understanding that each Staff Member and Director has special talents and capabilities necessary to fulfill LSCC’s Mission, Vision, and Values.
      • Principles of AIDET (Acknowledge, Introduction, Duration, Explanation and Thank You) at all times with patients, colleagues, visitors and leadership
    • The Language of Caring skills are versatile life skills that enhance communication and strengthen relationships that apply to all of us, whether we serve patients and families directly, or we serve the people who do—our internal customers.





    • Graduate of an accredited nursing school
    • Valid Texas LVN or RN license
    • BLS (CPR & AED) certification issued by the American Heart Association (AHA)
    • Minimum of two (2) years of experience in a clinical setting or an equivalent analytical position consistent with the needs of the position




    • Proficiency with EMR system
    • Proficiency with MS Office Suite (Word, Excel, and Outlook)
    • Bilingual English/Spanish language skills
    • CPHQ certified or the ability to obtain CPHQ certification within 6 months of hire


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