Catholic Health Initiatives RN - Quality Management Coordinator (Medical Staff Services) Full Time in HOUSTON, Texas

RN - Quality Management Coordinator (Medical Staff Services) Full Time


Baylor St. Luke’s Medical Center

A quaternary care facility that is home of the Texas Heart® Institute, a world-class cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD–consistently ranked as one of the nation’s best in Cardiovascular Services & Heart Surgery.

The first hospital in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award four consecutive times. Baylor St. Luke’s is home to three freestanding community emergency centers (Holcombe, Pearland, and San Felipe) offering adult and pediatric care–treating more than 51,000 patients annually.The hospital holds a collaborative partnership with Baylor College of Medicine and affiliations with The University of Texas Medical School at Houston, The University of Texas Medical Branch (Galveston), Houston Baptist University, and Prairie View A&M University.

Position Summary

Manages the medical staff quality performance improvement program; Assesses the clinical systems, processes and outcomes related to treatment provided by the medical staff and Assists in planning performance improvement activities; Provides documentation of individual practitioners and organizational performance in accordance with standards and regulatory agencies. The position is a resource for addressing quality concerns related to the organization, patient, payers and community.


Minimum Requirements

Education: Bachelor's Degree

Licensure: Registered Nurse (RN)

Experience: Five (5) years of clinical nursing experience

Position Responsibilities

  1. Applies theoretical and clinical knowledge to planning quality improvement programs for the medical staff. Ensures compliance with medical staff bylaws and institutional policy within the peer review process

  2. Manages the implementation of medical staff peer review programs that improve individual medical staff performance as well as system, process, and outcome performance

  3. Assists the medical staff in studying physician performance by performing case review, aggregate data analysis, reporting to the medical staff sections and services, and reporting to the Quality of Care and Patient Safety Committee and Medical Executive Committee

  4. Maintains accurate and complete documentation of medical staff peer review, performance improvement, and medical staff reappointment activities

  5. Educates and Supports the medical staff in methods of improving CHI St. Luke's Health performance and quality initiatives

  6. Collaborates with individual physicians, physician leadership, hospital administration including risk management and legal services, and other healthcare professionals as needed

  7. Manages assigned service lines and peer review activities to facilitate total quality improvement processes for practitioners and for the hospital

  8. Manages information to ensure compliance with mandates of various regulatory agencies

  9. Utilizing principles of shared governance, the MSQM is responsible writing policy and procedures, creating job descriptions and evaluation forms, and hiring and training of new employees for the department. The MSQM will participate in the Quality of Care and Patient Safety Committee and service meetings

  10. Partners with Information Technology to ensure integrity of data, and as needed for the department

Job RN


Daily Schedule Full Time

Scheduled Hours per 2-week Pay Period 80

Weekends Required None

Req ID: 2018-R0178822

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.