Quality Nurse Lead

Overview

The Quality Nurse Lead provides day-to-day functional oversight, guidance, and workflow coordination for the Quality Nurse team and is accountable for the timely completion and accuracy of the team’s assigned reviews of deceased patient records for organ and tissue donation potential. The role supports education and training, monitors deadlines and review status, assists with urgent reviews and audit variances, and collaborates closely with the Senior Director of Quality to address escalations from Hospital Services. The Quality Nurse Lead assigns and reprioritizes work within departmental priorities, monitors individual and team performance, provides coaching, and follows through on review deficiencies. The role provides functional oversight without direct personnel supervision; formal personnel decisions remain with the Senior Director of Quality and Human Resources. The role also supports continuous improvement of donation practices, resolution of issues related to hospital death lists, and strong cross-departmental relationships.

The Quality Nurse Lead supports and fosters the mission of LiveOnNY and its commitment to organ, eye, and tissue donation. All services performed in this role must be conducted in compliance with applicable federal and state laws, regulations, and oversight requirements, including but not limited to CMS, New York State, FDA, OPTN, and all applicable LiveOnNY policies, standard operating procedures (SOPs), and work instructions.

EXEMPT ROLES – FULL PROFESSIONAL DEDICATION AND AVAILABILITY

This exempt position requires the Quality Nurse Lead to devote full professional time, attention, and best efforts to LiveOnNY. The Quality Nurse Lead shall remain available to fulfill the position’s leadership and operational responsibilities inside and outside standard business hours as LiveOnNY’s needs dictate. The Quality Nurse Lead shall not undertake outside employment, consulting, or business activity, whether compensated or uncompensated, without advance written approval from the Chief Operating Officer in accordance with LiveOnNY’s Conflicts of Interest Policy.

Responsibilities

• Team Oversight and Support

• Provides day-to-day oversight and guidance to Quality Nurses and is accountable for the quality and timely completion of assigned team reviews.

• Assists with onboarding, education, and ongoing training of Quality Nurses to support performance and maintain knowledge of applicable industry standards and internal processes.

• Monitors individual and team review accuracy, status, performance metrics, and completion timelines; provides timely feedback and coaching; and escalates persistent performance or quality concerns to the Senior Director of Quality.

• Coordinates and supports urgent reviews and escalates issues as necessary to minimize delays in the referral review process.

• Assigns and reprioritizes daily reviews within departmental priorities, tracks progress, addresses review backlogs, and escalates barriers that cannot be resolved within the Lead’s authority.

• Audits variances in review processes, helps identify root causes, coordinates corrections with Quality Nurses and leadership, and verifies that assigned corrections are completed. Escalates unresolved or recurring deficiencies to the Senior Director of Quality.

• Death Record Review

• Coordinates with hospitals to obtain comprehensive lists of all hospital deaths within a specified timeframe.

• Reviews deceased patient records to determine whether organ and tissue donation referral criteria were met.

• Documents and submits review findings accurately and in a timely manner.

• Maintains and updates status reports on completed and pending reviews, ensuring data integrity.

• Communicates review progress and findings to departmental leadership.

• Builds and maintains effective working relationships with Medical Records Departments and key stakeholders in service area hospitals.

• Continuously works to improve reporting accuracy and timeliness.

• Tracks, trends, and analyzes key metrics and presents data in a clear and meaningful manner.

• Internal Audit Record Review

• Conducts audits of hospital medical records for donors and non-donors, focusing on identification of clinical triggers for organ donation referral.

• Collaborates with leadership to identify opportunities for improvement in donation practices.

• Supports internal performance improvement initiatives and contributes to the development of strategies to increase organ recovery.

• Prepares reports on audit findings and works closely with the team and leadership to support implementation and tracking of approved corrective actions.

• Escalation Management

• Works directly with the Senior Director of Quality to resolve escalations from Hospital Services and support timely resolution of issues affecting the donation process.

• Assists with troubleshooting and resolving issues related to obtaining hospital death lists to support accurate and timely information for review.

• Team Collaboration and Communication

• Fosters a collaborative environment across departments to support high-quality practices.

• Demonstrates professionalism, respect, and patience in all interactions with co-workers, stakeholders, and customers.

• Proactively identifies and communicates issues, barriers, or concerns related to the donation process and suggests solutions as appropriate.

• Participates in ongoing quality improvement efforts and process improvement initiatives (e.g., Lean, Six Sigma, PDSA).

• Encourages colleagues and stakeholders at all levels to contribute to quality enhancement efforts.

• Professional Development

• Actively participates in continuing education and professional development opportunities.

• Technical Proficiency & Documentation Systems

• Utilizes LiveOnNY electronic donor record systems and other communication systems and applications, and related documentation tools to manage workflow.

• Ensures accurate and timely data entry in accordance with LiveOnNY SOPs and regulatory standards.

• Compliance & Documentation

• Maintains complete and accurate documentation of assigned death record reviews, internal audits, and team oversight activities.

• Performs assigned review, audit, and functional oversight responsibilities in accordance with applicable CMS, OPTN, NYS AGA, FDA, and LiveOnNY requirements.

• Participates in QAPI reviews, case reviews, audits, and performance improvement initiatives as assigned.

• Maintains confidentiality consistent with LiveOnNY policies and standards.

• Professional Conduct

• Exhibits and maintains professionalism in high-stress and time-sensitive environments.

• Exercises sound clinical judgment within assigned death record review and internal audit responsibilities. The role does not provide direct patient or donor care or make donor-suitability or recovery decisions.

• Escalates complex or ambiguous clinical, regulatory, and/or ethical situations to leadership immediately.

Other duties may be assigned.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below represent the knowledge, skills, and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

REQUIRED

• Current Registered Professional Nurse (RN) license in the State of New York.

• Bachelor of Science in Nursing (BSN) from an accredited institution.

• Master’s degree in Nursing or a related field.

• Minimum of three years of clinical nursing experience, including at least two years of experience in chart review and medical record data abstraction.

PREFERRED

• Experience in critical care, emergency care, organ donation, or transplantation.

• Experience in quality improvement, regulatory compliance, or organ procurement processes.

• Knowledge of medical terminology, anatomy, physiology, and ICD-10 coding.

• Previous experience in audit, performance improvement, transplant care, or care of critically ill neurological patients.

• Knowledge of or experience with process improvement methodologies (e.g., Lean, Six Sigma, RCA).

ADDITIONAL REQUIREMENTS

• Strong lead-level coordination, coaching, and workflow oversight skills, with accountability for assigned team review accuracy, completion, and correction of deficiencies. Personnel supervision remains with the Senior Director of Quality.

• Strong analytical and problem-solving skills to evaluate data, draw conclusions, and recommend improvements.

• Proficiency with common computer applications, including Word, Excel, and PowerPoint.

• Excellent communication skills, both written and verbal, to present findings clearly to all levels of staff.

• Ability to work in a fast-paced environment and manage multiple priorities.

• Strong interpersonal skills to effectively interact with medical professionals and internal teams.

• Ability to apply critical thinking and clinical knowledge when assessing potential organ and tissue donation opportunities.

• Availability for an on-call rotating schedule, including evenings and weekends.

• Must be able to meet physical demands of the job, including standing, walking, lifting, and using vision for data analysis.

PHYSICAL DEMANDS

• The Quality Nurse Lead performs most duties while seated at a designated workstation, with occasional standing and walking.

• The Quality Nurse Lead frequently uses a keyboard, mouse, and other work devices, requiring repetitive movement of the hands, wrists, and fingers.

• The Quality Nurse Lead regularly speaks and listens during telephone or headset conversations.

• The Quality Nurse Lead uses close vision to read and process text, numbers, and data on computer screens.

• The Quality Nurse Lead may occasionally be required to lift or move up to 15 pounds.

• Uses reliable transportation in order to travel throu...