Quality Stroke & Sepsis Coordinator - FT

If you're looking for a place to call home and grow, Three Crosses Regional Hospital is looking for you! We are looking for Quality Stroke & Sepsis Coordinator that is committed to clinical excellence and building a patient-centered culture.

Three Crosses Regional Hospital is an advanced independent healthcare organization led by a local team of professionals dedicated to high quality patient care and being the first choice of patients and providers in the communities we serve.

We are dedicated to hiring team members that will adapt to our culture, pride themselves in professionalism, integrity, transparency, two-way communication, and ensuring the safety and well-being of our patients and staff.

The Stroke and Sepsis Program Coordinator is responsible for coordinating and advancing the hospital’s Stroke and Sepsis programs. This position promotes consistent, evidence-based care and ensures compliance with applicable accreditation, regulatory, clinical, and quality-reporting requirements.

The Coordinator serves as the organizational subject matter expert for Stroke and Sepsis, working closely with physicians, nursing, emergency services, ancillary departments, and Quality leadership. Responsibilities include program oversight, clinical data abstraction and validation, performance monitoring, case review, survey readiness, and coordination of improvement initiatives.

The Coordinator is expected to attend Stroke and Sepsis activations when on duty, observe the clinical response, and provide timely feedback and real-time education to the care team. The position also provides ongoing staff and provider education based on identified trends, case reviews, performance results, and changes in clinical or regulatory requirements.

This position analyzes clinical outcomes and performance trends, identifies gaps in care or documentation, and works collaboratively with department leaders to develop and monitor corrective actions. The Coordinator prepares reports for

hospital leadership and committees and ensures accurate, timely submission of required data to accrediting bodies, registries, and regulatory agencies.

The incumbent performs all duties in accordance with the highest standards of ethical and professional conduct and supports the mission, vision, and values of Three Crosses Regional Hospital.

Primary Responsibilities

• · Serves as the primary coordinator for the hospital’s Stroke and Sepsis programs, ensuring compliance with

  applicable certification standards, regulatory requirements, clinical guidelines, and performance measures.

  · Leads Stroke certification and Sepsis program readiness activities, including documentation review, gap analysis,

  action planning, tracers, and follow-up monitoring.

  · Attends Stroke and Sepsis activations when on duty to observe the clinical response, promote adherence to

  established protocols, and identify opportunities for improvement.

  · Provides timely, constructive feedback and real-time education to physicians, nurses, and other members of the care

  team following clinical activations and case reviews.

  · Coordinates and performs accurate clinical data abstraction, validation, entry, and submission for Stroke and Sepsis

  measures, registries, and required reporting platforms.

  · Reviews medical records and supporting documentation to evaluate compliance with clinical pathways, treatment

  timeframes, documentation requirements, and established standards of care.

  · Monitors clinical performance measures and outcomes, including treatment timeframes, bundle compliance,

  complications, mortality, transfers, readmissions, and other established indicators.

  · Analyzes performance data and identifies trends, barriers, and opportunities for clinical and operational

  improvement.

  · Prepares reports, dashboards, case summaries, and performance updates for hospital leadership, medical staff,

  committees, clinical departments, and accreditation review.

  · Conducts and participates in case reviews, tracers, focused audits, and other performance-improvement activities

  related to Stroke and Sepsis care.

  · Collaborates with physicians, nursing leadership, emergency services, pharmacy, laboratory, radiology, respiratory

  therapy, informatics, education, and other departments to support timely, standardized, and coordinated care.

  · Works with department leaders and frontline staff to develop, implement, and monitor corrective actions and

  performance-improvement plans.

  · Develops and provides ongoing education and orientation for staff and providers regarding Stroke and Sepsis

  · Participates in the development, review, and revision of Stroke and Sepsis policies, protocols, clinical pathways, order sets, and educational materials.

  · Coordinates Stroke and Sepsis committee activities, including meeting preparation, case presentation, data reporting, action-item tracking, and follow-up.

  · Collaborates with the Quality Data Analyst and Quality leadership to ensure data accuracy, integrity, and alignment with certification and regulatory requirements.

  · Maintains complete, organized, confidential, secure, and survey-ready program documentation, case files, educational records, and correspondence.

  · Participates in Stroke certification surveys, program reviews, and required follow-up activities.

  · Remains current with changes in certification standards, CMS requirements, evidence-based clinical guidelines, and applicable regulatory expectations.

  · Serves as a resource to clinical teams and promotes a collaborative, nonpunitive approach to case review, education, and continuous improvement.

  · Attends meetings, committees, and workgroups related to the Stroke and Sepsis programs, as assigned. · Performs other duties as assigned.

Education and Experience

· Required: Associate degree in nursing from an accredited nursing program.

· Preferred: Bachelor of Science in Nursing.

· Required: Minimum of three (3) years of hospital or acute-care nursing experience.

· Preferred: Experience in Stroke, Sepsis, Emergency Services, Critical Care, Quality, clinical data abstraction, or

performance improvement.

· Required: Must meet all Employee Health and organizational onboarding requirements.

License/Certification(s)

· Required: Current, unrestricted Registered Nurse license or multistate privilege to practice in New Mexico.

· Required: Current Basic Life Support certification.

· Preferred: Stroke-related, Sepsis-related, quality, or clinical specialty certification.

“We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law”.