Clinical Quality Nurse

General Notes

The Clinical Quality Nurse plays a vital role in enhancing clinical outcomes, safety initiatives, and operational efficiency through data-driven continuous quality improvement (CQI) initiatives. This position leads multidisciplinary teams in analyzing performance metrics, identifying opportunities for improvement, and ensuring continuous readiness for regulatory surveys.

Reporting to the Associate Director of Clinical Quality, the Clinical Quality Nurse serves as a trusted consultant, educator, and facilitator while fostering an environment of ongoing improvement and excellence. By aligning improvement strategies with organizational goals and regulatory requirements, this role supports measurable advancements in patient safety, care delivery, and compliance.

Purpose

The Clinical Quality Nurse supports and leads clinical quality, patient safety, regulatory readiness, and performance improvement initiatives. This role uses clinical expertise, data analysis, continuous quality improvement methodologies, and multidisciplinary collaboration to identify opportunities for improvement and implement sustainable solutions.

The position partners across clinical and operational teams to align quality improvement strategies with organizational goals and regulatory requirements while advancing patient safety, care delivery, compliance, and operational performance.

Responsibilities

Leads Multidisciplinary Quality Improvement Initiatives

• Facilitate team collaboration to support business outcomes and clinical excellence.
• Develop and implement CQI plans using methodologies such as PDSA and Lean.
• Champion change and help others adapt to new tasks and processes.
• Encourage team members to follow procedures and policies while fostering innovation.

Conducts Data Analysis and Performance Reporting

• Extract and analyze clinical and operational data to identify trends and improvement opportunities.
• Conduct statistical analysis to determine reliability and confidence intervals.
• Create charts, graphs, and narrative summaries using multiple data systems.
• Present quality metrics to teams and leadership to demonstrate impact.

Supports Regulatory Compliance and Survey Readiness

• Ensure continuous readiness for CMS, TJC, NCQA, and other regulatory bodies.
• Participate in survey preparation, mock audits, and documentation reviews.
• Develop and monitor corrective action plans to address compliance gaps.
• Serve as a subject matter expert on internal policies and external regulations.

Facilitates Risk Management and Patient Safety Activities

• Conduct root cause analyses, failure mode and effect analyses, and other assessments.
• Review event reports and escalate high-risk issues for resolution.
• Assist with developing targeted improvement strategies based on findings from audits, claim denials, and satisfaction surveys.
• Promote a safety culture and support incident prevention strategies.

Educates and Consults with Clinical Staff

• Deliver educational programs on regulatory requirements, internal concerns, and system usage.
• Coach staff on documentation standards, safety protocols, and quality practices.
• Participate in committees and projects to influence policy and procedure development.
• Build collaborative partnerships to improve compliance and health outcomes.

Develops and Maintains Quality Reporting Tools

• Design dashboards and reports to track KPIs and benchmark performance.
• Integrate quality metrics into operational workflows and decision-making.
• Document and analyze trends, errors, and reporting findings.
• Support business-specific projects with creative, data-informed solutions.

Marginal or Periodic Functions

• Participate in accreditation mock surveys and emergency preparedness drills.
• Assist with grant applications or research projects related to quality and safety.
• Attend professional conferences and disseminate best practices.
• Serve as a liaison for external quality collaboratives and benchmarking groups.
• Support strategic planning and innovation initiatives across departments.
• Perform related duties as required.

Knowledge, Skills, and Abilities

Process Management

• Design and improve processes that are efficient, scalable, and aligned with organizational goals.
• Apply process mapping and agile methodologies to streamline workflows.
• Implement SOPs and monitor compliance with healthcare quality standards.
• Refine processes based on performance data and stakeholder feedback.

Problem Solving

• Use logic and data to identify root causes and develop effective solutions.
• Conduct root cause and risk assessments using applied data analysis.
• Evaluate the impact and sustainability of solutions through CQI frameworks.
• Make sound decisions under pressure using critical thinking.

Functional/Technical Skills

• Demonstrate deep knowledge of clinical standards, EMR systems, and regulatory frameworks.
• Apply expertise in clinical quality, healthcare compliance, and risk management.
• Navigate EMR platforms and reporting tools to extract and analyze data.
• Interpret and apply CMS, TJC, and NCQA standards to ensure compliance.

Drive for Results

• Consistently deliver high-quality outcomes aligned with strategic goals.
• Lead quality improvement initiatives aligned with organizational goals.
• Track and report KPIs to demonstrate progress and effectiveness.
• Encourage accountability and continuous development planning.

Interpersonal Savvy

• Build effective relationships across different teams and disciplines.
• Demonstrate excellent communication and negotiation skills with stakeholders.
• Facilitate multidisciplinary collaboration and consensus-building.
• Resolve conflicts constructively and promote shared ownership of outcomes.

Organizational Agility

• Understand how organizations work and adapt strategies accordingly.
• Align quality initiatives with strategic priorities and operational realities.
• Navigate complex systems and hierarchies to drive change.
• Build coalitions and foster partnerships across departments.

Customer Focus

• Prioritize patient and stakeholder needs in decision-making.
• Design improvements that enhance patient experience and safety.
• Incorporate feedback from patients and staff into quality initiatives.
• Balance clinical goals with regulatory and operational requirements.

Required Qualifications

• Bachelor’s degree in Nursing (BSN).
• Minimum of three years of experience in a clinical setting.

Relevant education or experience may be substituted as appropriate.

Preferred Qualifications

• Master’s degree in Nursing, Healthcare Administration, or Public Health.
• Minimum of two years of experience in clinical quality.
• Two years of experience in acute care, ambulatory care, or multi-site healthcare systems.

Licenses/Registrations/Certifications

Required

• Current RN license in the State of Texas.
• Basic Life Support (BLS) certification.

Preferred

• Certified Professional in Healthcare Quality (CPHQ).
• Clinical Nurse Leader (CNL) certification.
• Certification in Risk Management or Patient Safety, such as CPPS.

Salary Range

$79,890+ depending on qualifications

Working Conditions

• Standard office equipment.
• Repetitive use of a keyboard.
• May be exposed to occupational hazards such as communicable diseases, blood borne pathogens, ionizing and non-ionizing radiation, hazardous medications, and disoriented or combative patients, or others.

Required Materials

• Resume/CV
• 3 work references with their contact information; at least one reference should be from a supervisor
• Letter of interest

Important for applicants who are NOT current university employees or contingent workers: You will be prompted to submit your resume the first time you apply, then you will be provided an option to upload a new resume for subsequent applications. Any additional Required Materials (letter of interest, references, etc.) will be uploaded in the Application Questions section, where you may upload multiple files. Before submitting your online job application, ensure that all Required Materials have been uploaded. Once your job application has been submitted, you cannot make changes.

Important for Current University employees and contingent workers: As a current university employee or contingent worker, you must apply within Workday by searching Find UT Jobs . Log in to Workday, navigate to your Worker Profile, click the Career link in the left-hand navigation menu, and update the sections in your Professional Profile before applying. This information will be pulled into your application. The application is one page, and you will be prompted to upload your resume. In addition, you must respond to the application questions to upload any additional Required Materials noted above.