RN Quality & Performance Improvement Specialist

Froedtert South, Inc.; Pleasant Prairie (WI); On-site; USD 70,000 - 90,000; Full time

Job summary

A healthcare organization in Pleasant Prairie, Wisconsin, is seeking an RN Quality & Performance Improvement Specialist. This role involves overseeing quality metrics, supporting patient safety initiatives, and performing data analysis to improve healthcare outcomes. The ideal candidate will have a strong understanding of regulatory requirements and experience in a healthcare setting. A nursing degree and RN licensure in Wisconsin are required. This position offers an opportunity to work collaboratively across departments and improve the quality of patient care.

Qualifications

• 3+ years of experience as a Registered Nurse in a healthcare setting.
• Current Registered Nurse licensure in Wisconsin.

Responsibilities

• Oversees quality metrics across various settings.
• Supports patient safety initiatives and compliance.
• Serves as a resource for quality data and reporting.
• Performs medical record reviews for compliance.
• Provides education and consultation on quality metrics.

Skills

Quality metrics understanding

Patient safety principles

Regulatory requirements knowledge

Analytical skills

Communication skills

Interpersonal skills

Proficiency in Epic

Proficiency in Microsoft Excel

Proficiency in Microsoft Word

Proficiency in Microsoft PowerPoint

Education

Associate Degree in Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

Epic

Microsoft Office

Vizient

Job description

RN Quality & Performance Improvement Specialist

Primary Responsibilities

Quality Metrics & Performance Improvement

• Oversees assigned quality metrics across inpatient and ambulatory settings, including CMS, internal performance measures, and quality databases such as Vizient.
• Works as part of a team of RNs to provide support, guidance, and recommendations to operational leaders in their respective areas of focus.
• Each RN may have specialized areas of expertise or assigned programs, but the team collectively ensures consistent monitoring and improvement of quality and performance metrics.
• Performs data validation, trending, and root cause analysis to support sustainable performance improvement.

Patient Safety & Compliance

• Supports patient safety initiatives, event analysis, and mitigation strategies to reduce risk and improve outcomes.
• Assists with regulatory compliance activities related to CMS, Joint Commission, and other accrediting or regulatory bodies.
• Participates in readiness activities for surveys, tracers, audits, and regulatory reviews for hospital and clinic environments.

Data Analysis & Reporting

• Serves as a clinical and analytical resource for quality data, outcomes reporting, and performance dashboards.
• Develops and maintains reports, scorecards, and visualizations to support leadership and operational decision-making.
• Acts as a subject matter expert for quality databases such as Vizient, including metric definitions, methodology, weighting, and benchmarking.

Clinical Documentation & Medical Record Review

• Performs concurrent and retrospective medical record reviews to ensure accuracy, completeness, and alignment with quality and regulatory requirements.
• Educates and advises clinical teams on documentation practices that support quality outcomes and compliance standards.

Education & Collaboration

• Provides education, guidance, and consultation to clinical and operational leaders regarding quality metrics, patient safety, documentation, and performance improvement initiatives.
• Acts as a shared resource across the RN team, ensuring operational leaders have the data, tools, and expertise needed to design and monitor implementation plans.
• Collaborates with physicians, nursing leadership, IS, and operational teams to align workflows with quality goals.
• Supports interdisciplinary quality committees, workgroups, and performance improvement projects.

Additional Responsibilities

• Supports department workflow, project management, and prioritization of quality initiatives.
• Participates in special projects and other duties as assigned to support organizational quality and performance goals.

Minimum Education Required

• Associate Degree in Nursing (ADN) required
• Bachelor of Science in Nursing (BSN) preferred

Minimum Experience Required

• Three (3) years of experience as a Registered Nurse in a hospital or healthcare setting

Licenses / Certifications Required

• Current Registered Nurse licensure in the State of Wisconsin

Knowledge, Skills, & Abilities

• Strong understanding of quality metrics, patient safety principles, and regulatory requirements.
• Experience with CMS measures, Joint Commission standards, and quality databases such as Vizient.
• Proficiency in Epic and Microsoft Office applications (Excel, Word, PowerPoint).
• Strong analytical, organizational, communication, and interpersonal skills.
• Ability to work independently and collaboratively as part of a team.