QUALITY NURSE REVIEWER

ABOUT CAMPBELL COUNTY HEALTH

Campbell County Health (CCH) is more than just a hospital—we are a comprehensive healthcare system serving northeast Wyoming. Our organization includes Campbell County Memorial Hospital, a 90-bed acute care community hospital in Gillette; Campbell County Medical Group, featuring nearly 20 specialty and primary care clinics—including locations in Wright and Hulett; and The Legacy Living & Rehabilitation Center, a long-term care facility.

To be responsive to our employee’s needs we offer:

• Generous PTO accrual (increases with tenure)
• Paid sick leave days
• Medical/Dental/Vision
• Health Savings Account, Flexible Spending Account, Dependent Care Savings Account
• 403(b) with employer match
• , discounted on-site childcare
• And more! to learn more about our full benefits package

JOB SUMMARY

The Quality Nurse Reviewer supports compliance and survey readiness for regulatory agencies, including The Joint Commission, State of Wyoming, DNV, and CMS. This role conducts concurrent and retrospective medical record reviews to evaluate the quality of care at Campbell County Health. Responsibilities include assisting with legal requests, collecting and analyzing data, and preparing reports to support quality improvement initiatives. The Quality Nurse Reviewer serves as a resource, educator, and facilitator for quality programs, ensuring compliance with regulations and promoting process improvements and clinical best practices.

ESSENTIAL FUNCTIONS

• Serves as content experts and supports leaders in reviewing and implementing published standards for safe patient care and survey readiness.
• Works within the incident reporting system to help maintain and assist in follow-up by departmental, medical staff, and executive leaders.
• Manages the incident reporting system users and assists with reports. Works with the Information Technology (IT) staff regarding system updates and troubleshooting.
• Utilizes risk mitigation strategies by assisting and supporting process improvement projects and event analysis which may include RCAs, FMEAs, investigations, and medical record reviews.
• Reviews medical records and abstracts data from CMS quality reporting measures and works with vendors and affiliates to ensure timely reporting.
• Assists departmental leaders with reporting and data analysis as indicated or requested.
• Serves on various committees as needed and in the absence of the Quality/Risk Director.
• Facilitates provider OPPE/FPPE process and Advanced Practice Provider evaluations.
• Completes and maintains provider feedback reports, including data collection, validation, and trending. Assists medical staff with benchmarking and notification of providers regarding reports.
• Develops and assists with implementation and maintenance of various organizational policies and procedures, ensuring accuracy, efficiency, and compliance with regulatory requirements.
• Supports the hospital quality improvement and risk management programs.
• Attends departmental meetings and in-services as required.
• Maintains confidentiality of all personnel, patients, and medical staff information.
• Must be free from governmental sanctions involving health care and/or financial practices.
• Complies with the hospital’s Corporate Compliance Program including, but not limited to, the Code of Conduct, laws and regulations, and following hospital policies and procedures.
• Collaborates with software vendors and IT analysts to define, validate, and ensure accurate data capture for consistent and complete trending and regulatory reporting.
• Other duties as assigned. This list is non-exhaustive.

JOB QUALIFICATIONS

• Education
  • Graduate of an accredited school of nursing.
• Licensure
  • Registered Nurse, State of Wyoming.
• Experience
  • Minimum three (3) years of nursing experience.
• Certifications required
  • See Cardiopulmonary Resuscitation Certification Policy and Certifications/Education Requirements Policy.