Clinical Performance & Quality Coordinator

Nexus Health Systems Ltd•Houston, TX

About The Position

The Clinical Performance & Quality Coordinator is a non-clinical, administrative position that supports Clinical Services through coordination of performance monitoring, quality improvement initiatives, regulatory and accreditation readiness, reporting, and policy and procedure maintenance. The role partners closely with clinical leaders, physicians, and interdisciplinary teams but does not deliver patient care, make clinical decisions, or practice any healthcare discipline. The Coordinator applies data analysis, project coordination, and continuous improvement methods to strengthen clinical operations, survey readiness, and organizational performance across Nexus Health Systems facilities serving patients with neurodevelopmental disorders, traumatic brain injury, and complex medical and behavioral comorbidities.

Requirements

Bachelor’s degree from an accredited institution in healthcare administration, public health, business administration, health information management, or a related field required.
Three (3) to five (5) years of experience in healthcare quality, performance improvement, clinical operations, accreditation readiness, or a related healthcare administrative function required.
Strong analytical and data-management skills, with demonstrated ability to collect, organize, interpret, and present quality and performance data.
Advanced proficiency in Microsoft Excel and working proficiency in the full Microsoft Office suite.
Familiarity with electronic health record and event-reporting systems.
Excellent written and verbal communication skills, with the ability to translate data into clear narrative summaries for clinical and executive audiences.
Strong organizational skills, attention to detail, and ability to manage multiple concurrent projects with competing deadlines.
Sound judgment and the ability to recognize and respect the boundary between administrative coordination and clinical decision-making, escalating appropriately.
Collaborative interpersonal style with demonstrated ability to build trust with clinical leaders, physicians, and interdisciplinary teams.
Working knowledge of healthcare regulatory, accreditation, and quality frameworks (CMS CoP, CARF, DNV, The Joint Commission, Texas Administrative Code).
Commitment to confidentiality, professionalism, and the Nexus GOPTIC Core Values.

Nice To Haves

Master’s degree in a related field preferred.
Experience in a specialty hospital, rehabilitation, long-term acute care, behavioral health, or complex-care environment preferred.
Experience supporting survey readiness for CARF, DNV, The Joint Commission, or CMS-certified facilities strongly preferred.
Certified Professional in Healthcare Quality (CPHQ) through the National Association for Healthcare Quality (NAHQ) preferred.
Must maintain current certification in good standing during employment with this facility.

Responsibilities

Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems
Upholds the Standards of conduct and corporate compliance
Demonstrates honest behavior in all matters. To the best of the employee’s knowledge and understanding, complies with all Federal and State laws and regulations.
Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.
Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
Collaborates effectively with colleagues and other departments to ensure seamless service delivery.
Coordinates the collection, aggregation, analysis, and reporting of clinical performance and quality metrics, including nurse-sensitive indicators, patient safety events, core measures, and facility-specific quality indicators.
Supports clinical leaders in the planning, execution, and evaluation of quality improvement initiatives using PDCA (Plan-Do-Check-Act) or comparable structured improvement methodologies.
Prepares and distributes routine and ad-hoc dashboards, scorecards, and performance reports for operational leaders, quality committees, and executive leadership.
Maintains the clinical policy and procedure library in partnership with clinical leaders, including tracking of review cycles, version control, approval workflows, and archival of superseded documents.
Coordinates cross-functional meetings, project timelines, agendas, minutes, and action-item tracking for quality, safety, and clinical operations committees.
Defers all clinical judgment, patient care decisions, and scope-of-practice determinations to licensed clinical staff; escalates clinical questions to the appropriate clinical leader rather than interpreting or resolving them independently.
Supports the patient experience indirectly by ensuring quality data, reporting, and process improvement work translate into safer, more reliable, and more consistent care delivery.
Assists in the aggregation, trending, and reporting of patient and family experience survey data, grievance and complaint data, and service recovery outcomes for use by clinical leaders.
Maintains strict confidentiality of patient information accessed during audits, chart reviews, and quality reporting activities in accordance with HIPAA and Nexus policy; does not discuss or interpret clinical information with patients or families.
Refers all patient, family, and caregiver inquiries regarding clinical care, treatment, or patient rights to the appropriate licensed clinical leader, patient advocate, or risk management designee.
Promotes a culture of safety, transparency, and continuous improvement that reinforces the organization’s commitment to patients with neurodevelopmental conditions, traumatic brain injury, and complex comorbidities.
Ensures all activities adhere to healthcare regulations and organizational policies.
Participates in quality improvement initiatives to enhance service delivery.
Promotes a culture of patient safety which results in the identification and reduction of unsafe practices.
Coordinates accreditation readiness activities for applicable accrediting bodies (CARF, DNV, The Joint Commission) and CMS Conditions of Participation, including tracer preparation, mock surveys, document organization, and corrective action tracking.
Conducts and coordinates audits of clinical documentation, regulatory compliance indicators, and policy adherence under the direction of clinical leadership; summarizes audit findings and tracks follow-up actions.
Monitors regulatory and accreditation standards updates (Texas Administrative Code, CMS, CARF, DNV, The Joint Commission) and communicates changes to affected clinical leaders for action and policy revision.
Supports event reporting system administration, including data entry, trend analysis, committee report generation, and follow-up on assigned action items.
Maintains accurate, defensible, and organized documentation of quality, regulatory, and accreditation records in accordance with record-retention requirements.
Completes annual education requirements.
Maintains competency, as evidenced by completion of competency validation requirements.
Maintains competency and knowledge of current standards of practice, trends, and developments.
Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices.
Pursues and maintains professional development in healthcare quality, regulatory readiness, and process improvement; obtains and maintains recognized credentials such as CPHQ as applicable to role progression.
Monitors relevant accreditation manuals, CMS Conditions of Participation updates, and NAHQ Healthcare Quality Competency Framework guidance to inform ongoing skill development.
Promotes stewardship of hospital resources while ensuring quality patient care.
Supports identification and quantification of quality- and compliance-related financial risk, including avoidable costs, reportable events, and potential regulatory penalties.
Manages project timelines, meeting logistics, vendor coordination, and software/subscription utilization in a fiscally responsible manner.
Records time worked accurately and adheres to facility timekeeping and expense policies.
Performs other duties as assigned.