RN Analyst-Data-Quality

The Senior Performance Improvement (PI) Analyst is

responsible for developing, implementing, and maintaining

performance improvement processes related to medical staff peer

reviews, credentialing, and regulatory compliance. This role

collaborates with physicians, hospital leadership, and quality

teams to enhance patient safety, improve clinical outcomes, and

ensure adherence to accreditation and regulatory standards. The

Senior Analyst will utilize data analytics, process improvement

methodologies, and stakeholder engagement to drive performance

excellence and accountability within the medical staff. Medical

Staff Performance & Peer Review Process Management Develops,

implements, and oversees the Professional Practice Evaluation

Program ensuring alignment with medical staff bylaws, The Joint

Commission (TJC), CMS, and other regulatory requirements.

Collaborates with Process Improvement Nurse (PIN) to ensure Focused

Professional Practice Evaluation (FPPE) and Ongoing Professional

Practice Evaluation (OPPE) processes are enforced, thus ensuring

compliance with accreditation requirements. Collaborates with

physician leaders and credentialing staff to integrate performance

data into appointment, privileging, and reappointment processes.

Establishes criteria for practitioner-specific performance

measures, ensuring timely and objective peer reviews that foster

constructive feedback and improvement. Supports the Physician

Quality Management Committee with policy development, report

preparation, and coordination of peer review activities. Data

Analytics & Performance Reporting Designs and implements an

information management system for practitioner-specific performance

data, including trend analysis and peer review conclusions, in

collaboration with the Information Services Department. Analyzes

physician performance data, clinical outcomes, and peer review

findings to identify trends, patterns, and areas for improvement.

Develops dashboards, scorecards, and detailed performance reports

to track progress and compliance with peer review processes.

Maintains databases and records related to physician performance

and quality improvement. Regulatory Compliance & Accreditation

Readiness Ensures peer review processes comply with all

accreditations, licensure, and regulatory standards, including TJC,

CMS, and state health department regulations. Serves as a subject

matter expert during audits, surveys, and compliance reviews

related to physician performance and peer review activities.

Collaborates with risk management, medical staff services, and

quality teams to ensure ongoing accreditation readiness and process

improvements. Education, Training & Stakeholder Engagement

Conducts training sessions, workshops, and individualized coaching

for physicians and medical staff on FPPR processes, objectives, and

best practices. Develops educational materials such as guidelines,

toolkits, and FAQs to support peer review engagement and continuous

learning. Provides expert guidance to medical staff and leadership

on performance improvement methodologies and patient safety

principles. Process Improvement & Stakeholder Collaboration

Leads interdisciplinary committees and workgroups focused on

performance improvement initiatives. Process improvement

methodologies to enhance efficiency and effectiveness of peer

review workflows. Collaborates with IT, medical staff leadership,

and quality teams to optimize peer review processes and technology

integration. Facilitates discussions with physicians, hospital

leadership, and administrative teams to ensure ongoing feedback and

engagement in performance improvement efforts. Attends the Medical

Staff Department and / or division meetings. Administrative &

Leadership Support Assists department leadership with budget

preparation and projects related to performance improvement

initiatives. Supports strategic planning efforts related to

quality, performance review, and medical staff improvement.

Registered Nurse (RN) with an active, unencumbered license

required. Bachelor’s degree in healthcare administration, Nursing,

Public Health, or a related field required; Master’s degree in

healthcare administration, Quality Improvement, or related

discipline preferred. A minimum of five years of clinical nurse

experience required; with at least two years in quality,

performance improvement, or risk management in a healthcare

setting, and / or quality management or performance improvement

experience preferred. Proficiency in data analysis tools (Excel,

Tableau, Power BI) and medical staff credentialing systems

(Credentialing Stream, MD-Staff, Cactus, or similar), and work

experience involving clinical data abstraction, data presentation,

and statistics required. In-depth knowledge of The Joint Commission

(TJC), CMS, and medical staff performance review standards

required. Experience in hospital operations, accreditation

readiness, or physician performance review and medical staff

quality, healthcare quality, performance improvement, risk

management, and utilization / case management preferred. Proficiency

with MIDAS, Quality Management, Credential Streams (Verity)

Software, EPIC, Electric Medical Record (EMR) and Verge Safe Report

System preferred. Certified Professional Healthcare Quality (CPHQ)

preferred. Occasional travel to different hospital sites or clinics

may be required. As an EOE / AA employer, the organization will not

discriminate in its employment practices due to an applicant's

race, color, religion, sex, sexual orientation, gender identity,

national origin, and veteran or disability status.