Quality Improvement Analyst, RN

Location: Mount Carmel

The Quality Improvement Analyst RN is responsible for monitoring, analyzing, and trending hospital quality performance metrics, including electronic clinical quality measures (eCQMs), CMS Care Compare data, internal quality improvement indicators, and specialty program dashboards. This role supports regulatory and specialty reporting platforms such as AAOS registries, including the American Joint Replacement Registry (AJRR) and ASR reporting, as well as CMS, Leapfrog, and Joint Commission ORYX requirements.

The analyst ensures data integrity and reporting accuracy by validating measure specifications, documentation requirements, abstraction logic, and submission processes across all regulatory and registry programs. Performance is evaluated against national and state benchmarks and program‑specific expectations, with gaps and opportunities for improvement identified and prioritized. The analyst prepares dashboards, scorecards, and performance reports for leadership, quality committees, and interdisciplinary teams.

In collaboration with clinical departments, providers, nursing, pharmacy, and hospital leadership, the analyst facilitates root cause analysis of underperformance and supports the development and implementation of corrective action plans. This role guides and supports performance improvement methodologies, including Plan‑Do‑Study‑Act (PDSA) cycles, workflow redesign, and documentation improvement initiatives, with a focus on sustaining measurable improvements. Additional responsibilities include tracking performance over time, monitoring sustained gains, ensuring ongoing compliance with Leapfrog and ORYX measures, and escalating barriers to leadership as needed.

The coordinator supports program readiness and regulatory reporting for CMS Inpatient Quality Reporting (IQR), MBQIP, Joint Commission ORYX, Leapfrog Hospital Survey, and specialty registries, including participation in audits, abstraction validation, and data review activities. The role also includes monitoring updates to measure specifications and evolving regulatory requirements and translating changes into operational guidance.

This position plays a key role in identifying and prioritizing quality improvement opportunities, researching and evaluating required changes, and leading implementation efforts in partnership with clinical and operational teams. By analyzing workflows, performance data, and outcomes, the analyst supports the implementation, monitoring, and sustainment of quality improvements across the organization.

Benefits Summary

We are proud to offer a comprehensive benefits package, including:

* Health Insurance

* Medical, dental, and vision coverage options.

* Free internal prescription program

* Employer contributions to premiums.

* Retirement Plans

* 457(b) plan with employer matching.

* 401(a) plan for employer contributions.

* Paid Time Off (PTO)

* Vacation days: 12 to 27 days per year based on years of service

* Sick days: 12 days per year accruing to a maximum of 65 days.

* Holidays: 6 observed paid holidays

* Work-Life Balance

* Flexible work schedules

* Other Benefits

* Employer-provided life insurance with optional additional coverage available at the employee's expense.

* Short-term and long-term disability insurance

* Employee assistance programs (EAP)

* Health Savings Accounts

* Flexible Spending Accounts

* Professional development opportunities

* Scholarship and Tuition reimbursement

* Additional Perks

* Wellness programs

* Volunteer opportunities

* Productivity, retention, and referral bonuses

About Us

At Wabash General Hospital, we are dedicated to putting patients at the heart of everything we do. Guided by our motto, "people you know, helping people you love," we are committed to serving our community with care and compassion.

We offer services for all generations, striving to be the trusted healthcare destination throughout every stage of life. While we are honored to have received numerous awards recognizing our efforts to be the best, what truly sets us apart is the personalized experience we provide to our patients and their families.

Our compassionate and dedicated team is focused on delivering exceptional, individualized care to support patients and their loved ones every step of the way. Join us in making a meaningful impact in the lives of those we serve