GENERAL SUMMARY:

Leverages advanced nursing experience to lead the analysis of clinical quality performance programs and metrics, identifying actionable insights aligned with organizational goals. Facilitates ongoing compliance with regulatory, accreditation, and voluntary quality programs. Collaborates with leaders at all levels, providers, staff, and quality improvement teams to utilize nursing clinical expertise, data insights, and evidence-based practice to improve care processes and achieve patient-centered outcomes.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Provides expertise in quality performance programs from CMS, commercial payers, accreditation organizations, and related entities.

3. *Facilitates accurate and timely clinical quality data submissions to external entities in collaboration with IT and Data Analytics.

4. *Conducts clinical medical record reviews, utilizing nursing expertise, for quality measure abstraction, coded adverse event review, and clinical documentation improvement opportunities.

5. *Retrieves, assembles, and analyzes quality data using available benchmarks, nursing clinical knowledge, basic statistics, and evidence-based references to identify trends and actionable insights.

6. *Develops and maintains effective data visualizations and reports according to governance standards, in collaboration with Data Analytics.

7. *Develops and leads presentations on quality programs and performance insights.

8. *Serves as a liaison with regulatory, accreditation, and related entities, maintaining professional relationships, communication, and effective data submission for all requirements.

9. *Facilitates regulatory and accreditation surveys; hosts surveyors (often nurses), coordinates the survey process, and collaborates with internal stakeholders to develop effective follow-up plans.

10. *Coordinates the internal regulatory/accreditation tracer and process audit program, specializing in acute care nursing; utilizing clinical expertise and an interdisciplinary team, to ensure survey-readiness.

11. *Monitors changes in regulatory and accreditation requirements, communicating and coordinating to ensure sustained compliance.

12. *Consults to align effective measures and contribute to teams and projects, improving clinical workflows, clinical documentation, regulatory compliance, and patient-centered outcomes.

13. Supports the development and maintenance of organizational policies, procedures, and related documents, aligned with accreditation and regulatory requirements, along with evidence-based practice.

14. Supports the development, implementation, and ongoing assessment of the Quality and Safety Plan, and Corporate Compliance Plan.

15. Provides coaching and education to cross-functional nursing and clinical quality roles to support their development and standardization of workflows.

16. Maintains professional growth and development in healthcare quality through courses, webinars, publications, coaching/mentoring, or professional affiliations.

17. Participates in meetings, committees/quality teams, and projects as assigned.

18. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk “*”).

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of anatomy, physiology, disease processes, and medical/pharmacological terminology.

2. Knowledge of hospital systems, medical records, coding principles, and reimbursement requirements.

3. Knowledge of regulatory, accreditation, and quality program standards.

4. Knowledge of operational excellence, standard metrics, and healthcare performance processes.

5. Knowledge of data governance, lifecycle management, and healthcare-related equipment, software, and tools.

6. Skill in quantitative and qualitative data collection, modeling, visualization, and analysis.

7. Skill in Microsoft 365 and job‑related software applications.

8. Skill in project management, change management, and facilitation of meetings, events, and shared decision‑making.

9. Skill in systematic, scientific improvement methods.

10. Skill in developing educational content, SOPs, reports, and data visualizations.

11. Ability to communicate effectively with diverse audiences and maintain strong working relationships.

12. Ability to prioritize multiple responsibilities and maintain confidentiality.

13. Ability to coach, mentor, and support colleagues.

14. Ability to adapt, learn, and perform effectively in rapidly changing environments.

15. Ability to interpret standards, validate measurement systems, and generate actionable insights from clinical and operational data.

16. Ability to manage interdisciplinary projects and complete accurate, timely submissions to external entities.

17. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Bachelor’s degree in Nursing, Health Information Management, Public Health, Healthcare Administration, or related field required. Current Registered Nurse license from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Minimum of five (5) years of progressive clinical experience in an acute care or comparable healthcare setting required. Clinical experience must include involvement in quality, patient safety, performance improvement, or regulatory activities.

OTHER CREDENTIALS / CERTIFICATIONS:

Certification relevant to quality, safety, accreditation, or performance improvement preferred.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Involves sitting most of the time, but may involve walking or standing for brief periods of time.