RN Quality & Performance Improvement Specialist

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.

Minimum Education Required

• Associate Degree in Nursing (ADN) required
• Bachelor of Science in Nursing (BSN) preferred

Minimum Experience Required

• Three (3) years of experience as a Registered Nurse in a hospital or healthcare setting

Licenses / Certifications Required

• Current Registered Nurse licensure in the State of Wisconsin

Knowledge, Skills, & Abilities

• 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.