Quality Improvement Analyst RN

Wabash General Hospital•Mt Carmel, IL

1d•$32 - $40

About The Position

The Quality Improvement Analyst RN is responsible for monitoring, analyzing, and trending hospital quality performance metrics, including electronic clinical quality measures (eCQMs), CMS Care Compare data, internal quality improvement indicators, and specialty program dashboards. This role supports regulatory and specialty reporting platforms such as AAOS registries, including the American Joint Replacement Registry (AJRR) and ASR reporting, as well as CMS, Leapfrog, and Joint Commission ORYX requirements. The analyst ensures data integrity and reporting accuracy by validating measure specifications, documentation requirements, abstraction logic, and submission processes across all regulatory and registry programs. Performance is evaluated against national and state benchmarks and program‑specific expectations, with gaps and opportunities for improvement identified and prioritized. The analyst prepares dashboards, scorecards, and performance reports for leadership, quality committees, and interdisciplinary teams. In collaboration with clinical departments, providers, nursing, pharmacy, and hospital leadership, the analyst facilitates root cause analysis of underperformance and supports the development and implementation of corrective action plans. This role guides and supports performance improvement methodologies, including Plan‑Do‑Study‑Act (PDSA) cycles, workflow redesign, and documentation improvement initiatives, with a focus on sustaining measurable improvements. Additional responsibilities include tracking performance over time, monitoring sustained gains, ensuring ongoing compliance with Leapfrog and ORYXX measures, and escalating barriers to leadership as needed. The coordinator supports program readiness and regulatory reporting for CMS Inpatient Quality Reporting (IQR), MBQIP, Joint Commission ORYX, Leapfrog Hospital Survey, and specialty registries, including participation in audits, abstraction validation, and data review activities. The role also includes monitoring updates to measure specifications and evolving regulatory requirements and translating changes into operational guidance. This position plays a key role in identifying and prioritizing quality improvement opportunities, researching and evaluating required changes, and leading implementation efforts in partnership with clinical and operational teams. By analyzing workflows, performance data, and outcomes, the analyst supports the implementation, monitoring, and sustainment of quality improvements across the organization.

Requirements

Registered Nurse (RN) license.
Experience in quality improvement analysis.
Knowledge of electronic clinical quality measures (eCQMs).
Familiarity with CMS Care Compare data.
Experience with internal quality improvement indicators.
Understanding of specialty program dashboards.
Knowledge of regulatory and specialty reporting platforms (AAOS registries, AJRR, ASR, CMS, Leapfrog, Joint Commission ORYX).
Ability to ensure data integrity and reporting accuracy.
Skill in validating measure specifications, documentation requirements, abstraction logic, and submission processes.
Ability to evaluate performance against benchmarks.
Proficiency in identifying and prioritizing improvement opportunities.
Experience preparing dashboards, scorecards, and performance reports.
Ability to facilitate root cause analysis.
Experience supporting the development and implementation of corrective action plans.
Knowledge of performance improvement methodologies (PDSA cycles, workflow redesign, documentation improvement).
Ability to track performance over time and monitor sustained gains.
Experience ensuring compliance with Leapfrog and ORYX measures.
Ability to escalate barriers to leadership.
Experience supporting program readiness and regulatory reporting (CMS IQR, MBQIP, Joint Commission ORYX, Leapfrog Hospital Survey, specialty registries).
Experience participating in audits, abstraction validation, and data review.
Ability to monitor updates to measure specifications and regulatory requirements.
Skill in translating regulatory changes into operational guidance.
Ability to research and evaluate required changes.
Experience leading implementation efforts.
Skill in analyzing workflows, performance data, and outcomes.

Responsibilities

Monitoring, analyzing, and trending hospital quality performance metrics.
Supporting regulatory and specialty reporting platforms (e.g., AAOS registries, AJRR, ASR, CMS, Leapfrog, Joint Commission ORYX).
Ensuring data integrity and reporting accuracy by validating measure specifications, documentation requirements, abstraction logic, and submission processes.
Evaluating performance against national and state benchmarks and program-specific expectations.
Identifying and prioritizing gaps and opportunities for improvement.
Preparing dashboards, scorecards, and performance reports for leadership and quality committees.
Facilitating root cause analysis of underperformance in collaboration with clinical departments and leadership.
Supporting the development and implementation of corrective action plans.
Guiding and supporting performance improvement methodologies (e.g., PDSA cycles, workflow redesign, documentation improvement).
Tracking performance over time and monitoring sustained gains.
Ensuring ongoing compliance with Leapfrog and ORYX measures.
Escalating barriers to leadership as needed.
Supporting program readiness and regulatory reporting for CMS IQR, MBQIP, Joint Commission ORYX, Leapfrog Hospital Survey, and specialty registries.
Participating in audits, abstraction validation, and data review activities.
Monitoring updates to measure specifications and evolving regulatory requirements.
Translating regulatory changes into operational guidance.
Identifying and prioritizing quality improvement opportunities.
Researching and evaluating required changes.
Leading implementation efforts in partnership with clinical and operational teams.
Analyzing workflows, performance data, and outcomes to support quality improvements.