Major Responsibilities: Quality Assessment and Performance Improvement 8)Assists in maintaining program policies, procedure, and protocols. 9)Assists with the development and recommendations for corrective action, to improve patient quality and safety when undesirable patterns are identified. Active participant in root cause analysis of sentinel events that occur within the Transplant Program. Communicates events and findings with Transplant Administrator and appropriate staff. 10)Proactively identifies data variances and communicates to department leadership. Monitors and reports program compliance with CMS and UNOS reporting requirements. 1)Demonstrates the ability to use multiple systems and clinical applications to collect, evaluate, and enter transplant and living donor data to ensure compliance with regulatory reporting requirements. 2)Prepares timely, logical, and accurate quality score cards for use in program QAPI activities. 3)Participates in audits, data collection, validation, analysis, and reporting to support program quality assurance and performance improvement (QAPI) initiatives. 4)Performs retrospective and/or concurrent patient medical record reviews/audits to abstract clinical data for program QAPI activities and assessment of compliance with corrective action plans. 5)Annually coordinates a review of the PI indicators defined for each program and makes recommendations for revisions. 6)Supports and assists the Transplant Administrator in coordinating and facilitating the transplant and VAD quality meetings. 7)Documents, prepares, and maintains minutes from the transplant and VAD quality meetings. Accreditation and Regulatory Compliance 5)Assists with coordinating and scheduling of announced visits/surveys. 1)Maintains current knowledge of requirements related to CMS Conditions of Participation, DNV VAD Disease Specific Certification for VAD, and UNOS Policies and Bylaws. 6)Assists in preparation of UNOS reports including annual personnel report, changes in key personnel (this would be new) and reports requested by the Membership and Professional Standards Committee. 2)Prepares and maintains materials/documents used for surveys by CMS, UNOS, and DNV. 7)Monitors and tracks compliance with UNOS requirements for data submission. Works with management if there is not full compliance. 8)Oversee the maintenance of the OPTN data entry system for transplant centers (TIEDI). Oversee the accurate reporting of all graft losses and patient deaths via TIEDI in a timely manner. 9)Primary interface with regulatory agencies (CMS, UNOS, DNV). 10)Revises documentation forms and consent forms as indicated. 3)Assists in the preparation of action plans in response to regulatory surveys. 4)Assists the Transplant Administrator and staff to assure continuous readiness for survey with policy and procedure development, review and revision, mock survey drills, and ongoing education. Quality Related Initiatives 1)Assists in the completion of UNOS/insurer’s RFI on an annual basis 2)Assists in analysis and prediction of patient and graft survival as will be reported via SRTR cohorts. Licensure: Nurse, Registered (RN) Education/Experience Required: Nursing Degree (BSN )required • 7+ years recent transplant coordinator experience •3 year + Quality experience and/or NAHQ certification • Graduate from an accredited school of nursing Knowledge, Skills & Abilities Required: Strong analytical skills • Proven leadership skills • Good organizational skills • Basic computer knowledge • Effective communication and presentation skills. • Exposure to transplant databases (UNOS and OTTR) Nursing License in the State of Illinois Physical Requirements and Working Conditions: • Ability to work flexible hours according to customer needs. • May be exposed to hazardous materials and life threatening diseases. • Ability to prioritize independently and respond to multiple simultaneous requests. • Lifting to 20 pounds occasionally and /or up to 10 pounds frequently. • Ability to communicate with staff, physicians, patients/families • Ability to travel locally and nationally. • Ability to work within stressful conditions and difficult situations. Ability to work with outside regulators If position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.