Quality Nurse RN

Pioneer Medical Center is seeking a full-time RN nurse to lead our Quality, Risk Mitigation and Compliance activities. We are, essentially, the county hospital for Sweet Grass County, Montana. We are in a beautiful valley along the Yellowstone River, between three mountain ranges, just north of Yellowstone National Park. We serve our neighbors (ranchers, miners, tradespeople and retirees) and the many tourists who come here on their way to Yellowstone and Glacier National Parks, or to fish the Yellowstone, hike, bike, hunt or just get away from overcrowded other places. Big Timber is a stable, vibrant and welcoming small town. Our schools are good, with a lot of community & parent support, our housing prices are very reasonable. Look through our website, the FB groups "Big Timber Community" and "Big Timber Buzz", or call our HR Director at 4O6.93two.46O3 for more information about the area and this role.

Pioneer Medical Center provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, pregnancy, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

The Job Description:

With minimal direct supervision or direction, the Quality Nurse for Pioneer Medical Center (PMC) has the responsibility, accountability and strategic ownership for quality and patient safety endeavors at PMC, providing procedures, guidance and exemplary hands-on work developing and continuously improving PMC’s culture of quality patient care, risk mitigation and regulatory compliance.



1. Supports and models behaviors consistent with PMC’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as they relate to the environment, employee, patient safety and/or job performance.

2. In her/his role as the organization’s leader in healthcare quality activities, she/he develops, implements and supports quality improvement, risk mitigation and compliance policies, practices and documentation activities. Serves as PMC’s Compliance and Privacy Officer.

3. Monitors related industry developments, studies and results. Analyzes and uses research data and activity outcomes in designing, documenting and implementing Best Known Practices from throughout the healthcare environment. Provide guidance and oversight of peer review process that supports the achievement of continuous improvements in patient care.

4. Consults with, and informs, the DON regarding plans, changes and challenges in implementing work activities.

5. Ensures that all departments establish and maintain quality improvement programs. Collects reviews and maintains data relative to all quality, infection control and patient safety activities of facility operations and areas of clinical concern. Assists departments in evaluating the effectiveness of quality improvement activities.

a) Collects data on admissions and throughout hospital stay from the medical chart for quality of care screening, trending and for medical staff committees. Is aware of individual patient population needs. Acts as a resource to the clinical team to assure appropriateness of the plan of care and clinical documentation.

b) Receives and compiles statistics related to all unusual occurrences not limited to but including patient and visitor incidents. Coordinates the investigation and resolution of patient complaints in a timely manner.

c) Provides oversight of the collection of accurate data that is reported to outside agencies to comply with regulatory requirements and meet the expectations of various quality initiatives.

d) Serves as a resource on each clinical team for questions related to Medicare coverage and documentation to support a system of total quality improvement.

e) Provide guidance and oversight of peer review process that supports the achievement of continuous improvements in patient care.

f) Coordinates infection control processes and data for review and improvement. Services as a resource for infection control standards.

6. Develops, implements, and maintains the facility compliance program. Monitors the performance of the Compliance Program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.

a) Develops initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the compliance program.

b) Collaborates with other departments to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with CEO and legal as needed to resolve difficult legal compliance issues.

c) Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations.

d) Acts as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated, and resolved.

e) Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.

f) Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future.

g) Provides reports on a regular basis, and as directed or requested, to keep the Compliance Committee of the Board and senior management informed of the operation and progress of compliance efforts.

h) Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required

i) Establishes and provides direction and management of the compliance Hotline

j) Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.

7. Maintains unit-based customer relationships and visible, approachable, collegial relationships with managers and staff. Works closely with the Trauma Coordinator.

8. Performs all other duties as assigned or as needed to meet the needs of the department/organization.



• HIPAA and confidentiality requirements

• Healthcare information management principles

• Common policies and procedures, both organizational and departmental

• Code of Business Conduct

• PMC compliance activities

• Patient’s/resident’s rights

• Patient safety standards

• Montana’s CAH standards, CMS, OSHA & FDA regulations

• Resources for required federal, state, and local laws applicable to the health care environment

• Quality and process improvement principles and tools

• Change management theories and principles

• Health care trends

• Health care risk management principles

• Electronic Medical Record Documentation

• Regulatory reporting requirements

• Microsoft Office suite programs (Excel, Power Point, Word, Outlook, etc.)

• Exemplary customer service


• Practices within scope of Registered Nurse

• Clinical knowledge

• Professional communication skills, both written and verbal

• Critical thinking skills

• Developing policies and procedures

• Strategic planning

• Work effectively with nursing and other healthcare team members. Exemplary “collaborative mindset” presence

• Aware of, and works effectively in, PMC’s close-knit community environment

• Management and leadership

• Group facilitation

• Demonstrating empathy and sensitivity necessary to elicit patient or visitor cooperation and allay apprehensions

• Time management, organization and prioritization

• Process improvement techniques

• Basic statistics, data collection, analytical tools, accurate report writing


• Provide proactive and reactive quality patient care, risk mitigation and compliance.

• Provide leadership to related activities of employees, teams and committees

• Establish and maintain collaborative relationships within PMC, with external agencies and other stakeholders related to these activities.

• Effectively interact with employees, leadership, providers, the Board, and members of the community.

• Provide meaningful reports that reflect best use of data, statistical analysis and graphics

• Respond verbally and/or in writing to immediate requests, and project a command presence of dedication, concern, sincerity, confidence and competence

• Work effectively with frequent interruptions and competing priorities

• Interpret guidelines for patient care and service and policies; identify non-compliance and take appropriate action


• Directs and oversees the development of improvement, risk mitigation and compliance processes and documentation that directly impact PMC’s strategic goals and healthcare provision objectives

• Communicates on PMC’s behalf , speaking to its vision, values, and strategic goals

• Decisions that impact patients, employees and the community may have health & legal implications

• Decisions can impact PMC’s licensing/accreditation status

• Decisions regarding spending have direct impact on PMC’s financial viability

• Position requires frequent& effective interaction with administration, medical staff, management, employees, and external organizational relationships, attorneys, and customers.

• Accountabilities typically include planning and development up to a five (5) year scope.


• Bachelor’s Degree in Nursing, Masters in healthcare-related discipline preferred

• Current Montana RN license, or ability to transfer another jurisdiction’s RN license to Montana within 30 days

• Three to five years’ experience as a Nurse, in hospital health care

• Current in ACLS-Advanced Cardiac Life Support

• Teaching experience helpful

• An equivalent combination of education and experience relating to the above tasks, knowledge, skills and abilities will be considered

• Legally able to work in the US, in a federally-funded healthcare organization


• Work is performed in a variety of environments to include patient care areas within the hospital, clinics and long-term care facility, office, and/or classroom

• Occasional outside work may be required, at any time of the day, in any weather

• Frequent participation in video & in-person meetings

• Frequent visits/rounding on patient care areas

• Some immunizations, clothing or other protective measures may be required.

• May require travel with occasional overnight stays

Blood Borne Pathogen Category: Category II: Tasks that may involve occasional exposure to blood, body fluids or tissues, but are not a part of the routine job description. Appropriate protective measures are readily available to every employee engaged in Category II tasks.

Airborne Contaminant Category: Category II: Tasks that on occasional basis may involve exposure to airborne contaminants.


The above is intended to describe the general content of and requirements of the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements.

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