Clinical Quality Analyst Deaconess Health System - 3.5 Evansville, IN Job Details 3 hours ago Qualifications Meeting minutes Data quality checks Medical performance measurement report preparation Portfolio monitoring Operational analysis Nursing Power BI Data visualization software proficiency Office activity coordination Quality records maintenance Defect resolution root cause analysis Electronic health records (EHR) management Healthcare Administration

CMS HIPAA

Gap analysis Metrics Reporting Mid-level Associate's degree in healthcare administration Tableau Trend analysis Data summary reports Quality reports Meeting scheduling Quality control data reporting Clinical audit and monitoring Data integrity and documentation Medical administrative support CMS regulatory compliance Clinical performance metrics Full Job Description Primary Responsibilities Quality Data Abstraction & Reporting Collect, abstract, and validate clinical and operational quality data across all joint ventures, ensuring accuracy and completeness for internal and external reporting. Maintain and update quality scorecards, performance dashboards, and tracking tools on a regular basis to reflect current performance across the JV portfolio. Generate recurring and ad hoc quality performance reports for the Quality Program Supervisor, joint venture leadership, and physician partners. Support accurate documentation and submission of quality and cost performance data in compliance with CMS, MSSP, ACO, and other value-based care program requirements. Performance Monitoring & Gap Analysis Monitor quality metrics and performance benchmarks across all joint ventures, flagging variances, trends, and care gaps for supervisor review and action. Analyze data to identify root causes of quality score variances and support the development of targeted performance improvement initiatives. Track care gap closure activities across joint ventures, coordinating with clinical staff and physician offices to ensure timely completion and documentation. Support the preparation of performance summaries and trend analyses to inform physician engagement and leadership decision-making. Care Coordination Support Assist in coordinating care gap closure workflows between hospital and physician group partners, helping to reduce service duplication and improve care transitions. Support outreach efforts to patients and care teams to facilitate completion of outstanding quality measures and preventive care activities. Maintain organized records of care coordination activities, follow-up actions, and outcomes across joint venture entities. Meeting Coordination & Administrative Support Coordinate and prepare materials for quality meetings, performance reviews, and joint venture leadership presentations, including agendas, data summaries, and follow-up action items. Maintain organized documentation of meeting minutes, governance decisions, performance records, and compliance activities across the JV portfolio. Support the onboarding of new joint venture programs by assisting with data setup, reporting infrastructure, and workflow integration. Compliance & Audit Support Assist in maintaining audit-ready documentation for regulatory and payer reviews, ensuring quality and performance records are complete and accessible. Support the development of Plans of Correction (POC) by compiling data, tracking corrective action progress, and documenting outcomes. Ensure data abstraction and reporting activities align with HIPAA privacy standards, CMS program requirements, and joint venture governance policies.

Qualifications Education:

Preferred:

Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or a related field.

Preferred:

Bachelor's degree in a healthcare or data-related discipline.

Experience:

1-3 years of experience in healthcare quality, data abstraction, performance reporting, or a related role. Experience in an ACO, value-based care, or joint venture environment is a plus. Familiarity with CMS quality programs, Stars measures, or risk adjustment preferred.

Technical Skills:

Proficiency in Electronic Health Records (EHR) systems and quality reporting tools. Experience with data visualization or reporting platforms such as PowerBI, Tableau, or Excel. Strong attention to detail with demonstrated ability to manage and validate large data sets accurately.

Knowledge Areas:

Working knowledge of CMS regulations, value-based payment models, and quality reporting requirements. Familiarity with Stars quality measures and care gap closure processes. Understanding of HIPAA privacy standards and healthcare data governance practices. Scope & Impact Supports quality performance across all joint ventures within the Deaconess Health System portfolio. Contributes directly to CMS Star Ratings, shared savings performance, and regulatory compliance through accurate and timely data support. Reports to the Quality Program Supervisor of Joint Ventures; collaborates with physicians, clinical staff, and operational leaders across joint venture entities. Plays a key role in building scalable, standardized quality infrastructure to support the continued growth of the JV portfolio.