RN Quality & Performance Improvement Specialist
Froedtert Health
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.
- 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.
- Associate Degree in Nursing (ADN) required
- Bachelor of Science in Nursing (BSN) preferred
- 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.
- Medical, dental and vision benefits available
- 403(b) company match available
- Tuition reimbursement
- Employee discount program
- Competitive PTO
Vacancy posted 12 hours ago
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