Clinical Quality Analyst

GENERAL SUMMARY

Responsible for the collection, validation, analysis, and reporting of clinical quality data to support regulatory compliance, accreditation, payer programs, and organizational performance improvement. Serves as the technical and analytical backbone of the clinical quality program, ensuring that data is accurate, timely, and aligned with required specifications. Works in close partnership with Quality Outcomes Specialist (RN) and clinical leaders, who provide clinical interpretation and validation of quality measures.

PRINCIPAL JOB FUNCTIONS

1.

• Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2.
• Collects, abstracts, validates, and submits clinical quality data for regulatory, accreditation, payer, and internal reporting programs in accordance with defined measure specifications and timelines. 3.
• Retrieves, assembles, and analyzes clinical quality data from the electronic health record (EHR), registries, and other clinical systems to support quality improvement intiatives, compliance, and organizational performance goals. 4.
• Performs data analysis using multiple methods to identify trends, gaps, and opportunities for improvement; prepares accurate, clear, and actionable reports, dashboards, and visualizations for clinical and operational stakeholders. 5.
• Ensures data quality, integrity, governance, and standardization by applying defined data definitions, validation rules, and audit processes; investigates and resolves data discrepancies. 6. Supports regulatory, accreditation, and voluntary reporting requirements, including preparation of required files, documentation, and supporting evidence for audits, surveys, and external submissions. 7.
• Provides analytical and data support to medical staff, hospital committees, quality improvement teams, and leadership, including responding to requests for clinical data and performance metrics.

8. Identifies and communicates opportunities for clinical documentation improvement and data process enhancements to support accurate quality measurement and reporting. 9. Maintains current knowledge of regulatory, payer, and accreditation quality measure requirements and ensures timely incorporation of specification changes into data abstraction and reporting workflows. 10. Uses EHRs, reporting platforms, and other clinical and analytical tools to extract, manage, and analyze data; assists with system configuration, testing, and optimization related to quality reporting. 11. Supports continuous improvement of quality data workflows, automation, and reporting efficiency. 12. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 13. Participates in meetings, committees, and departmental projects related to quality measurement, reporting,, and performance improvement. 14. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk "

• ").

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES

1. Knowledge of disease process to include basic anatomy and physiology, sufficient to support clinical quality and performance improvement activities. 2. Knowledge of medical and pharmacological terminology as it relates to clinical documentation, quality measurement, and reporting. 3. Knowledge of hospital systems, including the design and function of electronic health records and medical record documentation. 4. Knowledge of coding principles and documentation requirements relevant to quality reporting and reimbursement. 5. Knowledge of quality improvement principles, methodologies, and applicable regulatory and accreditation standards. 6. Knowledge of data management concepts, basic statistical analysis, and principles of healthcare informatics. 7. Proficiency with computer hardware, software applications, and Microsoft Offie Suite. 8. Ability to collect, validate, analyze, and present data to support quality, safety, and performance initiatives. 9. Ability to ensure data accuracy, completeness, and integrity. 10. Ability to communicate effectively, both verbally and in writing, with clinical and non-clinical stakeholders. 11. Ability to manage assigned projects, timeslines, and workflows. 12. Ability to prioritize demands and function with minimal supervision. 13. Ability to maintain confidentiality and appropriately handle sensitive information. 14. Ability to work effectively as a member of multidisciplinary teams. 15. Ability to establish and maintain effective working relationships with staff, leaders, medical staff, and ancillary departments. 16. Ability to navigate healthcare systems, policies, and processes to support quality initiatives. 17. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE

Associate's degree in Nursing, Health Information Management, Public Health, Healthcare Administration, or related field required. Minimum of two (2) years of relevant healthcare experience with demonstrated exposure to quality, data abstraction, reporting, compliance, or performance improvement required. Experience working with electronic health records (EHR) systems preferred. Experience with regulatory/quality reporting programs preferred.

PHYSICAL REQUIREMENTS

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Involves sitting most of the time, but may involve walking or standing for brief periods of time.