RN System Performance Improvement Coordinator (Community-Based)

Job Title: RN System Performance Improvement Coordinator (Community-Based)
Location: Danville, Pennsylvania
Job Category: RN - Registered Nurse, Nursing and Nursing Support
Schedule: Days
Work Type: Full time
Department: Accreditation Division
Date Posted: 11/12/2021
Job ID: R-22560

Job Summary

Responsible for assessing system compliance with regulatory standards and internal policies. Active participation in campus rounding to evaluate consistent survey readiness and compliance with applicable regulatory agency standards.

Evaluates the quality of health care rendered by the System for the purpose of Peer Review pursuant of the Medicare Act, as directed by, and as a member of the System's Performance Improvement Department, a Peer Review Subcommittee of Geisinger, by evaluating the quality of services ordered or performed by the System's professional healthcare providers including practice analysis, inpatient hospital utilization reviews, medical audits, and the compliance of assigned department, with the standards set by associations of healthcare providers and with applicable laws, rules and regulations. Responsible for coordinating and supporting Performance Improvement activities and identifying ongoing data and information system needs as part of the System's Peer Review process.

Job Duties

  • Demonstrates a comprehensive understanding of the theory and principles of clinical performance improvement.
  • Creates and fosters change in a positive proactive manner.
  • Fosters problem-solving using critical thinking skills.
  • Coordinates and participates in the development and implementation of regulatory programs and activities in the assigned areas and service lines
  • Reviews and monitors occurrences, quality triggers and quality of care concerns observing for problems or patterns affecting the quality of care for appropriate Peer Review protected action as assigned.
  • Educates and orients providers, administration, professional and line staff as needed regarding Performance Improvement requirements and methodologies in a Peer Review protected forum.
  • Serves as resource person for Performance Improvement initiatives  throughout the system
  • Assists with and provides direction to staff in developing measurements for Performance Improvement and evaluation activities.
  • Develops data collection tools, data collection, summarization of data and reporting of findings in a Peer Review protected process.
  • Schedules and assists with follow-up studies to determine effectiveness of corrective action in a Peer Review protected process.
  • Maintains appropriate records of all Performance Improvement activities.
  • Assists in the preparation and coordination of all regulatory surveys.
  • Actively participates in all surveys.
  • Conducts and coordinates the follow-up of survey recommendations and requirements.
  • Educates employees on changes in regulatory standards.
  • Facilitates, coordinates, and participates in multidisciplinary Peer Review protected Performance Improvement workgroups and projects, as assigned.
  • Reports potentially compensable events to the risk manager in a Peer Review protected process.
  • Coordinates and conducts Peer Review protected chart reviews for Medical Records and Procedure Committee within established time frames.

Work is typically performed in a clinical environment with FREQUENT travel throughout the Geisinger footprint. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

Position Details

Preferred Qualifications/Experience:

  • Experience with maintaining hospital compliance with regulatory agencies
  • Knowledgeable with PA DoH, CMS, and Joint Commission regulations and standards
  • Previous experience with completing action plans, licensure applications, plans of corrections and narrative submissions
  • Proficient in Microsoft Excel
  • LEAN Methodologies

Work Schedule/Details:

  • Monday through Friday: Typical hours are 8A to 4:30P
  • Systemwide travel to hospital and outpatient sites is required over 50% of the time
  • When you're not traveling, work can be conducted at your home office.

We’re proud to offer competitive salaries and a comprehensive benefits package that includes:

  • Medical, prescription drug, vision and dental coverage
  • Family Support (Fertility and Adoption Support)
  • Employer contribution to your retirement plan
  • Tuition assistance (part time and full time roles only)
  • Generous paid time off packages that allows you to take the time you need to travel, rest, and care for and reconnect with friends and family.
  • Professional opportunities for growth and advancement
  • Support and mentorship from a full range of dedicated and experienced nursing leaders
  • Paid Military Leave
  • Community Involvement through our Employee Resources Groups


Bachelor's Degree-Nursing (Required)


Minimum of 2 years-Managing people, processes, or projects (Required)

Certification(s) and License(s)

Basic Life Support Certification - Default Issuing Body; Valid Driver's License - Default Issuing Body; Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania

Our Purpose & Values

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
Salary Range
$41,000.00 - 72,000.00
per Year
Salary range estimated by
Danville, PA 17821, US
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