Sr. Analyst - Performance Improvement - Registered Nurse (RN)

Start the day excited to make a difference…end the day knowing you did. Come join our team.

Job Summary :

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.

Essential Functions and Responsibilities :

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

Regulatory Compliance & Accreditation Readiness

Education, Training & Stakeholder Engagement

Process Improvement & Stakeholder Collaboration

Administrative & Leadership Support

Qualifications :

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.