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Registered Nurse

Company: Lone Star Circle of Care
Location: Georgetown
Posted on: May 3, 2021

Job Description:

The Quality Department Nurse supports and assists the Quality Department in multiple aspects of quality-driven and regulatory initiatives, data tracking and trend reports related to quality and regulatory initiatives. Participates in staff education, employee health and infection prevention and control activities.

General Duties:

+ Assists in facilitating data collection, tracking and trending of clinical quality improvement activities in the simplest, most efficient manner.

+ Uses discretion to report matters of significance to the Chief Medical Officer/Chief Quality Officer (CMO/CQO) and Associate Director of Nursing and Quality (ADNQ) or other relevant parties.

+ Schedule, conduct, track emergency code drills and training to assist in the improvement of the emergency response team and facility emergency systems (e.g., response protocols, emergency drills, resource management and emergency communication)

+ Collaborate in evaluation of emergency drills and events

+ Assist with tracking and scheduling of outside inspections related to quality and safety, i.e. fire and medical equipment.

+ Assist in creating, maintaining and updating manuals and documents necessary for Joint Commission survey and/or other accreditations or recognitions, including tracking of compliance with all federal, state, and local requirements and various funding agencies related to Environment of Care and Safety

+ Participates in management of the Employee Health program for LSCC.

+ Demonstrates excellent customer service skills required for extensive interface with providers, staff and clients, including persons from diverse cultures and medically underserved populations.

+ Attends required meetings and participates in system wide councils or committees as requested, offers support and suggestions for ongoing Q/QA activities.

+ Maintain working knowledge of requirements of The Joint Commission (TJC), Texas Health Steps (THS), Department of State and Human Services (DSHS)-related programs, Health Resources and Services Administration (HRSA) and Bureau of Primary Health Care (BPHC), etc., as related to job duties.

+ Participates in performance improvement activities, as assigned, including clinical and environment of care (EOC) tracer activities on an assigned basis.

+ Works well under, and meets, deadlines, ensuring timely flow of information to, from and within the Quality Department.

+ All other duties as assigned.

Vaccine Duties:

+ Maintain competency and education related to vaccines, vaccine storage and handling, administration and immunization schedules.

+ Works closely with Clinic Site Managers/Vaccine Coordinators on all aspects of vaccine management.

+ Ensures compliance with all regulations related to vaccine management.

+ Provides vaccine and vaccine audit related education to staff in person and via the learning management system (LMS).

+ Communicate and work with the CMO/CQO and ADNQ to implement or provide immunization support deemed necessary.

+ Maintain a contact relationship with the Department of State Health Services (DSHS) Regional Vaccine Coordinators for associated regions.

+ Collaborates with the Director of Pharmacy, CMO/CQO, and ADNQ to assess need and order annual flu vaccine.

+ Assists with completion of new and annual site applications for Texas Vaccines for Children (TVFC) and Adult Safety Net (ASN) programs, hereafter noted as State Vaccines.

+ Prepares, completes, maintains, and submits reports on State and Private Vaccines.

+ Ensures that the clinic sites and NextGen IT staff have the current VIS for each vaccine.

+ Attend State/Regional trainings to support the vaccine program.

Audit Duties:

+ Achieves and maintains competence in NextGen in order to accurately abstract data for audits.

+ Maintains competence in NextGen medical records functions and compliance with HIPAA rules and regulations.

+ In coordination with the Custodian of Records, works with third party payers on patient medical record audits.

+ Maintains a working knowledge of documentation requirements for various programs including Texas Health Steps (THS) and other DSHS programs.

+ Performs documentation audits as required.

+ Prepares, completes, maintains, and submits reports on audit activities as requested.

IPC Duties:

+ Assist staff and management in the determination of reliable, valid, and measurable quality and patient safety indicators as related to IPIC.

+ Assists in monitoring data and trends related to IPIC.

+ Assists in ensuring cost effective, technology-based access to current information on IPIC and epidemiology including appropriate data collection and action plans.

+ Assists in the ongoing compliance with regulatory and accreditation requirements and best practices related to communicable disease management.

+ Collaborate with appropriate state and local health departments for reporting, surveillance, and follow-up of communicable diseases and related conditions.

+ Performs appropriate follow-up of communicable disease exposures in the clinical setting.

+ Monitors blood borne pathogen and infection control practices and prepare appropriate reports.

+ Provide staff training and education as related to IPIC.

+ Assists in new hire and annual health screens and immunizations.

+ Assists in coordinating the annual influenza immunization program.

+ Assists in the completion of all required annual and periodic reporting.


+ Graduate of an accredited nursing school

+ Valid Texas LVN or RN license

+ BLS (CPR & AED) certification issued by the American Heart Association (AHA)

+ Minimum of two (2) years of experience in a clinical setting or an equivalent analytical position consistent with the needs of the position


+ Proficiency with EMR system

+ Proficiency with MS Office Suite (Word, Excel, and Outlook)

+ Bilingual English/Spanish language skills

+ CPHQ certified or the ability to obtain CPHQ certification within 6 months of hire

External Company Name: Lone Star Circle of Care

External Company URL:

Street: 2423 Williams Drive

Keywords: Lone Star Circle of Care, Georgetown , Registered Nurse, Other , Georgetown, Texas

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