Clinical Quality Improvement RN | Analytics

Location:

Hospital Main Campus, 1418 College Dr, Mt Carmel, IL 62863, USA

Pay or shift range: $32 to $40. The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job‑related reasons.

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.

• 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
• 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
• Scholarship and Tuition reimbursement
• Wellness programs
• Volunteer opportunities
• Productivity, retention, and referral bonuses

Bachelors or better in Nursing.

Minimum of 2–3 years’ experience in healthcare quality, performance improvement, or data analytics. Knowledge of CMS quality programs and quality measurement concepts. Good PC skills with knowledge of excel preferred. Previous performance improvement skills with plan development and data analysis. Ability to navigate Excel preferred. Must be able to perform the essential functions of the job as defined in the job description.

Minimum of…