RN Quality & Performance Improvement Specialist
About The Position
Summary Primary Responsibilities Quality Metrics & Performance Improvement Oversees assigned quality metrics across inpatient and ambulatory settings, including CMS, internal performance measures, and quality databases such as Vizient. Works as part of a team of RNs to provide support, guidance, and recommendations to operational leaders in their respective areas of focus. Each RN may have specialized areas of expertise or assigned programs, but the team collectively ensures consistent monitoring and improvement of quality and performance metrics. Performs data validation, trending, and root cause analysis to support sustainable performance improvement. Patient Safety & Compliance Supports patient safety initiatives, event analysis, and mitigation strategies to reduce risk and improve outcomes. Assists with regulatory compliance activities related to CMS, Joint Commission, and other accrediting or regulatory bodies. Participates in readiness activities for surveys, tracers, audits, and regulatory reviews for hospital and clinic environments. Data Analysis & Reporting Serves as a clinical and analytical resource for quality data, outcomes reporting, and performance dashboards. Develops and maintains reports, scorecards, and visualizations to support leadership and operational decision-making. Acts as a subject matter expert for quality databases such as Vizient, including metric definitions, methodology, weighting, and benchmarking. Clinical Documentation & Medical Record Review Performs concurrent and retrospective medical record reviews to ensure accuracy, completeness, and alignment with quality and regulatory requirements. Educates and advises clinical teams on documentation practices that support quality outcomes and compliance standards. Education & Collaboration Provides education, guidance, and consultation to clinical and operational leaders regarding quality metrics, patient safety, documentation, and performance improvement initiatives. Acts as a shared resource across the RN team, ensuring operational leaders have the data, tools, and expertise needed to design and monitor implementation plans. Collaborates with physicians, nursing leadership, IS, and operational teams to align workflows with quality goals. Supports interdisciplinary quality committees, workgroups, and performance improvement projects. Additional Responsibilities Supports department workflow, project management, and prioritization of quality initiatives. Participates in special projects and other duties as assigned to support organizational quality and performance goals.
Requirements
- Associate Degree in Nursing (ADN) required
- Three (3) years of experience as a Registered Nurse in a hospital or healthcare setting
- Current Registered Nurse licensure in the State of Wisconsin
- Strong understanding of quality metrics, patient safety principles, and regulatory requirements.
- Experience with CMS measures, Joint Commission standards, and quality databases such as Vizient.
- Proficiency in Epic and Microsoft Office applications (Excel, Word, PowerPoint).
- Strong analytical, organizational, communication, and interpersonal skills.
- Ability to work independently and collaboratively as part of a team.
Nice To Haves
- Bachelor of Science in Nursing (BSN) preferred
Responsibilities
- Oversees assigned quality metrics across inpatient and ambulatory settings, including CMS, internal performance measures, and quality databases such as Vizient.
- Works as part of a team of RNs to provide support, guidance, and recommendations to operational leaders in their respective areas of focus.
- Performs data validation, trending, and root cause analysis to support sustainable performance improvement.
- Supports patient safety initiatives, event analysis, and mitigation strategies to reduce risk and improve outcomes.
- Assists with regulatory compliance activities related to CMS, Joint Commission, and other accrediting or regulatory bodies.
- Participates in readiness activities for surveys, tracers, audits, and regulatory reviews for hospital and clinic environments.
- Serves as a clinical and analytical resource for quality data, outcomes reporting, and performance dashboards.
- Develops and maintains reports, scorecards, and visualizations to support leadership and operational decision-making.
- Acts as a subject matter expert for quality databases such as Vizient, including metric definitions, methodology, weighting, and benchmarking.
- Performs concurrent and retrospective medical record reviews to ensure accuracy, completeness, and alignment with quality and regulatory requirements.
- Educates and advises clinical teams on documentation practices that support quality outcomes and compliance standards.
- Provides education, guidance, and consultation to clinical and operational leaders regarding quality metrics, patient safety, documentation, and performance improvement initiatives.
- Acts as a shared resource across the RN team, ensuring operational leaders have the data, tools, and expertise needed to design and monitor implementation plans.
- Collaborates with physicians, nursing leadership, IS, and operational teams to align workflows with quality goals.
- Supports interdisciplinary quality committees, workgroups, and performance improvement projects.
- Supports department workflow, project management, and prioritization of quality initiatives.
- Participates in special projects and other duties as assigned to support organizational quality and performance goals.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
501-1,000 employees
