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University of Rochester Pediatric Surgical Clinical Reviewer - 225471 in Rochester, New York

Pediatric Surgical Clinical Reviewer Job ID 225471

Location Strong Memorial Hospital Full/Part Time Full-Time Favorite Job Regular/Temporary Regular Opening

Full Time 40 hours Grade 044 Surgery Quality Assurance


Position Summary:

This position is responsible for the Quality Assurance and Performance Improvement (QA/PI) work for the Division of Pediatric Surgery and contributes to the Surgical QA/PI work for Golisano Children’s Hospital. In addition, this position is responsible for all clinical database work related to the American College of Surgeon’s Pediatric National Surgical Quality Improvement Program (ACS-P-NSQIP). This includes case selection, data collection and submitting reliable data to ACS-NSQIP. It also includes interpreting/analyzing quality outcomes with the responsibility to identify areas for PI and participating on teams to improve surgical outcomes for Surgical Pediatric Patients at URMC.


The position has opportunity for temporary remote working arrangements and works with minimal supervision in carrying out the designated duties and responsibilities of the position.

General Responsibilities:


  • Accurately identifies surgical patients for inclusion in the NSQIP-P program through the application of strict inclusion/exclusion criteria and protocols.

  • Complete and accurate collection of pre-operative, operative and post-operative data through the effective utilization of the EMR and other Hospital databases.

  • Demonstrates appropriate utilization of resources necessary for accurate and timely data entry into the program’s database and meeting the caseload accrual requirement protocol.

  • Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program through inter-rater reliability, (IRR) testing.

  • Contacts patients and/or families via telephone and/or written communications to complete the required NSQIP 30 day follow-up for identifying post-operative complications. Meets the required minimal follow-up compliance percent.

  • Serves as an educational resource on the ACS-NSQIP-P program.

  • Participates in PI Team and P-NSQIP Collaborative calls and attends national ACS-NSQIP conference annually.

  • Identifies areas for streamlining and process improvement in the data collection process.

    Division of Pediatric Surgery QAL: 15%

    Serves as the Quality Assurance Liaison (QAL) for the Division of Pediatric Surgery.

  • Works with Division Physician QAL to coordinate the ongoing development, implementation and monitoring of the Division’s QA/PI Program.

  • Oversees the Division Mortality and Morbidity (M&M) Case Review process ensuring a comprehensive peer review is in place, summarizes case reviews, enters into RL, coordinates Interdepartmental Case Review requests, and coordinates external agency review requests.

  • Coordinates the Division QA meetings and maintains attendance records.

  • Works with Division Physician QAL monitoring quality outcomes, developing processes to improve outcomes and tracks status of QA/PI plans.

  • Coordinates the investigation and resolutions of patient complaints.

  • Responsible for maintaining Physician QA files/profiles.

  • Coordinates the Division FPPE process.

  • Ensures Division complies with Hospital and external regulatory requirements.

  • Reports and coordinates reportable occurrences (NYPORTS) and participates in RCA reviews.

  • Represents the Division at the Department of Surgery QA Meeting, prepares monthly Quality Dashboards, reporting out when scheduled and prepares Division QA/PI Program presentation annually.

    Other QA/PI Work: 10%

  • Participates in QA/PI Initiatives to improve pediatric surgical outcomes.

  • Responsible for Hospital level Quality audits including H & P audits, SSI Bundle audits and others as requested.

  • Miscellaneous duties related to the Department of Surgery QA/PI initiatives as assigned.

    Other Responsibilities: 5 %

  • Attends Hospital, Department and Division level meetings and conferences as assigned.

  • Establishes effective working relationships with members of the Department of Surgery, Nursing, and all other Hospital Departments.

  • Other duties as assigned.

    Machines and Equipment Used

  • General office equipment and computer hardware/software.


  • Current NYS Registered Nurse license, Bachelor’s/Master’s degree preferred.

  • Three (3) years’ RN experience in acute care hospital with pediatric surgical specialty preferred, will consider other surgical specialty experience or equivalent combination of education and experience.

  • Ability to complete American College of Surgery P-NSQIP initial and annual training modules and certification exam.

  • Detail oriented with strong organizational/prioritization skills and ability to work independently under general guidance.

  • Proficiency in Microsoft Office (Word, Excel, PowerPoint), software/web applications, and electronic medical record.

  • Clinical chart review and abstraction experience preferred.

  • Experience in Quality Improvement and Lean preferred

    How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled