Quality Improvement Analyst, RN

About the role

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.

Responsibilities

• 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.
• Ensures data integrity and reporting accuracy by validating measure specifications, documentation requirements, abstraction logic, and submission processes across all regulatory and registry programs.
• Prepares dashboards, scorecards, and performance reports for leadership, quality committees, and interdisciplinary teams.
• Facilitates root cause analysis of underperformance and supports the development and implementation of corrective action plans.
• 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.
• Tracks performance over time, monitors sustained gains, ensures ongoing compliance with Leapfrog and ORYX measures, and escalates barriers to leadership as needed.
• 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.
• Maintains awareness of updates to measure specifications and evolving regulatory requirements and translates changes into operational guidance.
• Identifies and prioritizes quality improvement opportunities, researches and evaluates required changes, and leads implementation efforts in partnership with clinical and operational teams.
• Analyzes workflows, performance data, and outcomes to support the implementation, monitoring, and sustainment of quality improvements across the organization.

Qualifications

• Bachelor’s degree in Nursing (RN preferred)
• Current licensure as a Registered Nurse in the state of employment
• Experience in healthcare quality improvement, preferably in a hospital setting
• Strong analytical skills and ability to interpret complex data
• Excellent communication and interpersonal skills
• Proficiency in Microsoft Office applications, particularly Excel and PowerPoint
• Ability to work independently and as part of a team

Skills

• Data analysis and interpretation
• Quality improvement methodologies
• Regulatory compliance and reporting
• Collaborative problem-solving
• Effective communication and presentation skills

Benefits

We are proud to offer a comprehensive benefits package, including:

• Health Insurance
• Medical, dental, and vision coverage options
• Free internal prescription program
• Employer contributions to premiums
• Retirement Plans
• 457(b) plan with employer matching
• 401(a) plan for employer contributions
• Paid Time Off (PTO)
• Vacation days: 12 to 27 days per year based on years of service
• Sick days: 12 days per year accruing to a maximum of 65 days
• Holidays: 6 observed paid holidays
• Short-term and long-term disability insurance
• Employee assistance programs (EAP)
• Health Savings Accounts
• Flexible Spending Accounts
• Professional development opportunities
• Scholarship and Tuition reimbursement
• Wellness programs
• Volunteer opportunities
• Productivity, retention, and referral bonuses