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Performance Improvement/Risk Management Coordinator FT Days

Req #: 17008277
Location: Orange City, FL
Job Category: Risk Management
Organization: Florida Hospital Fish Memorial


Work Hours/Shifts

Full Time Day Shift 40 hours per week

Florida Hospital Fish Memorial

For a young hospital built in 1994, Florida Hospital Fish Memorial has a long history dating back to 1952. Beginning as a humble, 50 bed facility more than six decades ago, we’ve grown to become one of Volusia County’s most comprehensive and trusted healthcare resources. With Florida Hospital's tremendous resources and expertise, our community hospital has continued to thrive due to constantly improving advanced medical technologies and experienced clinical talent.


Through our dedication to excellence we have been recognized as Orlando Sentinel’s "Top 100 Companies for Working Families" for 9 consecutive years. We also received the Performance Achievement Award from the Medicare Quality Improvement Organization of Florida, as well as, the 24th Annual Commissioner’s Business Recognition Award from the Florida Educational Foundation and Florida Department of Education.


As a member of Adventist Health System, Florida Hospital Fish Memorialoperates as a not-for-profit organization focused on improving the health of the community it serves. This is a direct reflection of our mission to extend the healing ministry of Christ with skill and compassion." Best of all, it’s just a short trip from some of Florida’s most exciting attractions—and minutes from the beaches in Daytona!


What You Will Be Responsible For:


  • Serves as a hospital content expert on performance improvement projects, grievances, accreditation and safety. Provides leadership and support regarding questions from staff, leaders and physicians on performance improvement, risk and accreditation. Utilizes outside resources for complex questions to ensure correct communication and interpretation (i.e. TJC intranet, ECRI, QualityNet websites).
  • Participates in collaboration with or as the designee for the Quality Director, on AHS quality initiatives and/or collaboratives. This may include but is not limited to: Glycemic management, Partnership for Patients, AHRQ safety indications as assigned. Assists with data management, performance improvement, medical record review and meeting organization to help ensure initiative success and goals are met. Utilizes appropriate PowerInsight (PI) reports to coordinate performance improvement and safety projects.
  • Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, performance review councils, and hospital leadership meetings by providing risk management, quality and safety updates as assigned.  Responsible for ensuring all cases referred to Medical Review are dealt with according to hospital Medical Review policy and medical staff bylaws. This includes screening, reviewing with appropriate department chairman, preparing cases to be brought to committee, completing agenda/minutes for committee meeting, communicating committee decisions to involved medical staff providers and providing updates to Medical Executive Committee and hospital Executive Council. Maintains familiarity with medical staff bylaws as an internal content expert.
  • Plans, implements & monitors interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees and teams. Leads special projects for the Chief Medical Officer, Quality Director and Risk Manager while using judgment for the level of discretion and confidentiality needed.
  • Prepares reports and statistical analysis for medical staff and hospital leadership meetings.  Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. 
  • Risk management designee when risk manager and quality director are out of the hospital or need additional support. Complete and analyze Root Cause Analysis timelines, review risk events, notifies regulatory bodies of any Code 15 or other reportable events letters.
  • Assures facilitation of the patient grievance process as required by state and federal statutes. Assures that grievances are investigated and directs inquiries and complaints to appropriate directors and managers for follow up. Participates in grievance mediations when necessary. Active member of the board delegated grievance committee. Completes investigations of complaints about medical care which involve a member of the medical staff and communicates need for referral to the Performance Improvement Committee, medical director, Medical Review Committee and/or Citizenship Committee to the Risk Manager. Maintains data collection and grievance tracking and trending to include unsolicited complaints as well as solicited comments (Gallup surveys, SHARE boxes, etc.). Independently manages patient experience hotline and grievance/complaint calls and directs information to the appropriate member of the leadership team as appropriate.
  • Responsible for all incoming and outgoing correspondence, ensuring appropriate follow-up, including drafting of response correspondence.  Immediately advises Director and/or Managers of mail requiring a response and/or important or urgent mail. Writes correspondence on behalf of Director and/or Managers as necessary.
  • Oversees compliance with the Ethics, Rights, and Responsibilities standards for The Joint Commission. Ensures leadership and employee education on patient rights and responsibilities. Assist with New Hire Orientation and Nursing Orientation to provide education on performance improvement, accreditation and safety. Provides quarterly staff education and coordinates risk management activities for skills fair. May be asked by Quality Director to be responsible for developing weekly performance improvement, safety and accreditation tips education flyer and for completing rounds in clinical and non-clinical areas routinely to serve as a resource to staff.
  • Provides analysis of Physician Focus and Quality Advisor reports from the Premier database and produces recommendations for performance improvement projects to hospital leadership. Responsible for evaluation and completion of Premier Error Workbooks by the monthly deadline to ensure availability of evidence-based data analysis.
  • Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Provides concurrent case reviews and recommendations to ensure that evidence based best practices are implemented timely.  Responsible for independent coordination of program submissions in compliance with federal guidelines.
  • Responsible for reviewing patient medical records to determine adherence to key quality and safety initiatives. When discrepancy or variance is noted, responsible for notifying front line nurse, physician and/or leadership to ensure correction is made prior to discharge or chart completion deadline. Provides leadership for providers, managers and team members on accreditation awareness, safety initiatives, and performance improvement projects. Leads and participates in performance improvement initiatives to improve processes, value-based purchasing scores and to ensure patients receive evidence-based care according to the CMS and The Joint Commission standards.
  • Manages multiple calendars to coordinate meetings and events for internal and external stakeholders. Plans for and ensures the orderly occurrence of special events as scheduled. Prepares detailed itineraries when applicable to include events such as dinner meetings, physician meetings and presentations, direct reports’ retreats and special parties/receptions. Coordinates the attendees, materials and resources to ensure streamlined, meaningful performance improvement and risk management meetings/committees/ events. Completes minutes within forty-eight (48) hours or two (2) business days for review. Ensures follow up and includes action items in future agendas.
  • Administers and facilitates debriefing for the annual Safety Culture Survey, Joint Commission survey preparedness rounding, and completion and submission of the Leapfrog Survey.
  • Coordinates annual TJC standards review with executive team and directors and acts as Joint Commission Survey Liaison
  • Assists Quality Director, as assigned, to help with quality and safety initiatives throughout the year. Performs other duties as assigned. This includes, but is not limited to, maintaining department employee files in compliance with regulatory guidelines and maintain intranet for accreditation, risk management/safety, and performance improvement.


  • Bachelor’s degree
  • Minimum of 3 years’ healthcare experience
  • Previous experience in preparing and presenting professional presentations to executive leadership teams
  • Accreditation activities and survey preparation
  • Provider performance improvement activities



  • Bachelor’s degree in a healthcare related field
  • Experience with risk management, credentialing, grievances, Peer Review or OPPE process
  • Healthcare related performance improvement or project management experience
  • Proven ability in areas of leadership/ supervision, knowledge of regulatory aspects of healthcare, QA/QI principles, education and outcomes



  • Certified Professional in Healthcare Quality (CPHQ)
  • Six Sigma Performance Improvement Certification
  • Lean Performance Improvement Certification
  • Licensed Healthcare Risk Manager (LHRM)
  • Certified Joint Commission Professional (CJCP)

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
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