Clinical Quality Nurse

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** 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.  

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** 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
***…