Registered Nurse - Performance Measures Coordinator

Summary The Central Texas VA Health Care System is recruiting for a Performance Measures Coordinator Registered Nurse position. The incumbent leads quality improvement and performance measurement initiatives, collects and analyzes data, monitors compliance with policies and standards, identifies trends, supports evidence-based practice, collaborates with interdisciplinary teams, and promotes continuous improvement in patient care and organizational performance. Responsibilities The Performance Measures Coordinator is a fully developed position that executes continuous improvement responsibilities that demonstrate leadership, experience, and creative approaches to management of complex patient care. Facilitates the planning, monitoring, coordinating, and administrating recommendations for clinical and administrative Performance Measures (e.g. ORYX, Healthcare Effectiveness Data and Information Set (HEDIS), Patient Experiences, External Peer Review Program (EPRP), Electronic Quality Measures (eQM), Strategic Analytics for Learning and Improvement (SAIL). Provides direct support to Service Chiefs, Product Line Managers, and others in planning, designing, integrating, implementing, modifying, and evaluating the effectiveness of services to improve the performance measures and monitors. Provides real-time monitoring of all inpatients (acute, ICU, and surgical care) monitors and measures, Ambulatory Care (Primary Care, Specialty Care, Emergency Department), and Long Term / Residential Care (CLC, Domiciliary Programs). Actively functions as facilitator on Process Action Teams and Work Groups. Provides real-time, reliable, and accurate feedback and education to clinical leadership and clinical staff on findings of real-time monitoring. Reports performance measure issues to the leadership, Chief of Staff, and top-level management. Will be the facility's key person to help develop the medical center response in identifying performance measure improvement; identifies system problems and develops and implements appropriate interventions. Coordinates the EPRP activities including review of variances, analysis of results related to processes, and EPRP Exit Interviews. Possesses a thorough knowledge of the Office of Quality Performance (OQP) Measure Technical Manual. Provides education to all levels of the organization, especially to leadership, Service Chiefs, and champions on the performance measure process. Provides on-going education to clinical services and staff on the EPRP process, measures, and monitors outcomes at all CTVHCS sites. Coordinates and facilitates the Performance Measures Oversight Committee (PMOC). Supports and provides backup for the External Peer Review Program (EPRP). Support for EPRP includes attending and presenting on EPRP process, real-time monitoring, clinical dashboards, and outcomes at monthly Performance Measures Oversight Committee (PMOC) meetings and as needed in other meetings. Recommends champions for each performance measure and performance monitor, including supporting indicators. Disperses EPRP Data Accountability Checklists (DAC) to designated Service Chiefs and champions (e-mail encrypted or hard copies), on the EPRP process as soon as information is available to access on WVMI. Collects and organizes DAC appeals from Chiefs and champions prior to the EPRP exit. Coordinate with abstractor for review prior to the Exit Review date (minimum of one day prior). Submits the appeal spreadsheet to the ELB before the date of the EPRP Exit, if requested. Reviews EPRP Abstractor feedback with Chiefs and champions in order to conduct a second-level review of fallouts. Presents a preliminary DAC report to leadership upon request. Schedules and facilitates meetings between the EPRP Abstractor and Chiefs and champions as needed. Reviews potential appeals with VISN 17 Performance Measure staff prior to and immediately after EPRP Exit. Submits West Virginia Medical Institute(WVMI) and Office of Quality Performance(OQP) appeals immediately after evaluating feedback from VISN 17 Performance Measure staff. Proactively follows the appeal process and provides status and disposition updates to affected Chiefs and champions. Ensures the Abstractor has adequate technical and space resources prior to the arrival of the Abstractor. Performs other duties as directed. The Performance Measures Coordinator will provide an EPRP briefing at the morning report upon request. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Monday-Friday, 7:30 a.m. - 4:00 p.m. Telework: Position is eligible for Ad-Hoc Telework. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required Requirements Conditions of Employment U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement. Qualifications Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Preferred Experience: High performer, who functions independently and can navigate effectively within complex health care system. 1 year experience in analyzing hospital performance metrics (SAIL, EPRP, eQM, SHEP, VSignals). 1 year experience in leading multidisciplinary team/committee to facilitate process improvement. Lean Six Sigma Green or Black Belt Certified. Experience in driving process improvement through data analysis and LEAN methodologies. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. Reference: For more information on this qualification standard, please visit Physical Requirements: Light lifting under 15 pounds; light carrying under 15 pounds; reaching above the shoulders, use of fingers, walking 1-2 hours, standing 1-2 hours, both legs required, far vision correctable in one eye to 20/20 and to 20/40 in the other, both eyes required, ability to distinguish basic colors, hearing aid permitted; may be exposed to infected patients and contaminated equipment; may be expected to don protective equipment; may be exposed to combative patients; must complete annual Employee Health requirement. Education The Associate Degree Nursing (ADN), Bachelor of Science degree in Nursing (BSN), or Master of Science degree in Nursing (MSN) must be fully accredited by the Accreditation Commission for Education in Nursing (ACEN) or the Commission On Collegiate Nursing Education (CCNE). Verification of accreditation may be obtained from or If your school has changed names, or is no longer in existence, you must provide this information in your application. If your school was accredited by ACEN or CCNE at the time of graduation, but is no longer listed on the websites, you must provide documentation of accreditation with your application packet. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Additional Information This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.