Full Time 1. Works with the Director of Quality and other quality, clinical, and operational leaders to plan, design, implement, and maintain a comprehensive quality improvement program, including focused education of physicians and staff on quality, sepsis, and related patient safety initiatives. 2. Assists the Director of Quality in identifying, analyzing, and problem solving quality improvement issues, with dedicated responsibility for sepsis-related performance opportunities, trends, barriers, outcomes, and action planning. 3. Provides coordination and oversight of sepsis quality improvement activities, including early recognition, timely intervention, bundle compliance, case review, abstraction and validation processes, and follow-up on opportunities identified through quality review. 4. Supports compliance with quality improvement initiatives, regulatory expectations, accreditation readiness, and assigned quality and sepsis measures through record review, documentation validation, performance monitoring, and ongoing readiness activities. 5. Collects, abstracts, analyzes, and reviews quality and sepsis data, then prepares reports for regulatory agencies, accrediting bodies, internal committees, operational leaders, and medical leadership. 6. Maintains thorough and up-to-date knowledge of data definitions, evidence-based practices, regulatory requirements, reporting expectations, and national quality measures applicable to assigned program areas, including current and emerging sepsis reporting requirements. 7. Coordinates multidisciplinary sepsis improvement work across Emergency Services, nursing units, providers, pharmacy, laboratory, case management, information technology, and Quality Management to reduce variation in care and support sustained performance improvement. 8. Participates in staff meetings, quality committees, sepsis workgroups, and performance improvement activities; provides in-service training, education, coaching, and feedback to staff and providers as needed. 9. Provides support as needed by working closely with the IT team to optimize electronic medical record systems, clinical decision support tools, reporting workflows, and related clinical tools; utilizes software applications to prepare spreadsheets, graphs, charts, reports, and presentations; and demonstrates effective communication, teamwork, independent analysis, project leadership, and interdepartmental influence. Must have an active SC RN license required; bachelor's degree preferred. Minimum of two (2) years of related administrative, clinical, quality, regulatory, or compliance experience in a healthcare setting required. Experience with quality improvement, regulatory reporting, performance improvement, sepsis coordination, data abstraction, or compliance preferred. Must have strong analytical, communication, organizational, and multidisciplinary coordination skills.