Trauma Performance Improvement Nurse, *Sign-On Bonus Eligible*

UCSF Health; Oakland (CA); On-site; USD 125,000 - 175,000; Full time

Job summary

UCSF Health in Oakland is seeking a seasoned Registered Nurse to lead pediatric trauma quality improvement initiatives within the Benioff Children’s Hospital‑Oakland Trauma Program. You will drive performance improvement, data abstraction, and reporting to support ACS verification and national registries.

The role requires extensive QI knowledge, AIS/ISS experience, and strong organizational skills to manage multiple quality projects and collaborate with clinical staff and external agencies.

Qualifications

• Minimum 5 years experience as a Registered Nurse in a pediatric acute care hospital (trauma, ED, and/or critical care preferred).
• Bachelor’s degree in nursing or equivalent combination of education and experience.
• In‑depth knowledge of QI standards, chart review, abstraction, regulatory requirements.
• Advanced skills in QI tools, data collection, abstraction, validation, analysis, reporting and benchmarks.

Responsibilities

• Lead and participate in clinical and technical quality improvement projects using advanced QI models.
• Prepare and implement department QI plans, monitor progress, and report findings to management.
• Assist in patient‑specific QI issues with data preparation, CQI activities, and reporting.
• Support clinical areas in data management and development of quality indicators.
• Conduct incident reviews and collaborate on corrective actions.
• Attend and co‑lead trauma department meetings and QI activities.
• Generate routine reports and create dashboards from registry data.

Skills

Quality Improvement

Data Analysis

Project Management

Communication

Team Leadership

Education

Bachelor's degree in nursing

Tools

CAISS

LEAN training

AIS/ICD-10 training

Job description

Role Overview

The Benioff Children’s Hospital‑Oakland Trauma Program supports and sustains the hospital’s designation as a Level I Pediatric Trauma Center verified by the American College of Surgeons (ACS). The program ensures compliance with ACS standards, facilitates trauma center verification, and contributes to national trauma registries to benchmark performance, support research, and drive system‑wide improvement. It establishes and supervises processes such as performance improvement, clinical documentation, and quality improvement to achieve optimal patient care. It applies extensive knowledge of quality data analysis and improvement concepts to large, complex projects, writing reports, presenting data graphically, and engaging registry management and research activities.

Key Responsibilities

• Lead and participate in clinical and technical quality improvement (QI) projects using advanced QI models.
• Prepare and implement department QI plans, monitor progress, and report findings to management.
• Assist in patient‑specific QI issues, providing data preparation, CQI activities, and reporting.
• Support clinical areas in data management and project development of quality indicators.
• Conduct incident reviews, sentinel events, readmissions, and other high‑complexity cases, collaborating with management to develop corrective actions.
• Attend and co‑lead trauma department meetings, units, and hospital QI activities.
• Participate in the monthly registry meetings, training, and quality/operational improvement sessions.
• Maintain interaction with TQIP staff and other regulatory agencies to maximize compliance.
• Oversee and maintain the trauma registry database: validate documentation, abstract data, ensure accuracy, and meet submission deadlines.
• Generate routine reports for committee meetings and create dashboards, presentations, and action plans based on registry data.
• Participate in ACS verification site reviews, emergency medical service (EMS) audits, and data validation meetings.
• Engage in self‑development activities, pursuing in‑services and continuing education in QI and trauma registry standards.
• Provide technical leadership, mentor staff, share knowledge on registry data, and support trauma education.

Required Qualifications

• Minimum 5 years experience working as a Registered Nurse in a pediatric acute care hospital (trauma, ED, and/or critical care preferred).
• Bachelor’s degree in nursing or another health‑care profession, or an equivalent combination of education and experience.
• In‑depth knowledge of QI standards, clinical chart review, abstraction, and regulatory requirements.
• Advanced skills in QI tools, data collection, abstraction, validation, analysis, reporting, and use of performance and benchmark indicators.
• Knowledge of Alameda County trauma center designation requirements and ACS Trauma Verification standards.
• Experience with Abbreviated Injury Scoring (AIS), Injury Severity Scoring (ISS), trauma registry documentation, and ICD‑10 coding training.
• Exceptional organizational and project management skills with the ability to lead teams and manage multiple projects.
• Strong interpersonal and communication skills for collaboration with clinical and technical staff and external agencies.
• Proficient understanding of pathophysiology, medical terminology, and data compliance for clinical abstraction.
• Self‑driven: must pursue mandatory mandatory mandatory learning and networking (phrasing removed as placeholder).

Preferred Qualifications

• Post‑graduate degree in health sciences.
• Certified Specialist in Trauma Registry (CSTR).
• Certified Abbreviated Injury Scale Specialist (CAISS).
• LEAN training or similar quality methodology certification.
• TNCC certification.
• Advanced problem‑solving skills and knowledge of business and quality data management software.
• Strong influence and persuasion skills across departments.

License / Certification

• Current California Registered Nurse licensure.
• Current American Heart Association BLS certification.
• AAAM AIS Coding Course completion and American Trauma Society Registrar basic/advanced coursework.
• ICD‑10 Course Certificate within the past 5 years.

Equal Employment Opportunity

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

Benefits and Salary

Salary and benefits are subject to UC policy and collective bargaining agreements. For more information on compensation and benefits, please visit the UCSF compensation website.