Lead Quality Improvement Specialist

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

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The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Responsibilities:

ESSENTIAL FUNCTIONS

Clinical Quality & Regulatory Leadership  

Serves as the clinical quality & safety expert for assigned organizational initiatives. 

• Conducts comprehensive clinical review of medical records to evaluate documentation accuracy and collaborate with CDI & coding leaders to ensure compliance with regulatory requirements.
• Reviews medical records to evaluate and address quality of care opportunities, and adherence to evidence-based practice. 
• Performs detailed chart reviews related to CMS quality measures, accreditation standards, patient safety initiatives, and other internal and external quality programs. 
• Identifies trends, variations, documentation gaps, compliance risks, and opportunities for clinical improvement. 
• Interprets clinical findings and translates complex regulatory requirements into actionable recommendations for operational and physician leadership. 
• Partners with physicians, nursing leadership, advanced practice providers, and interdisciplinary teams to improve clinical quality, safety, and documentation practices. 

Quality Improvement Leadership

• Leads enterprise quality improvement initiatives resulting from chart review findings, quality performance data, regulatory requirements, patient safety events, and organizational priorities. 

• Develops improvement strategies utilizing Continuous Quality Improvement methodology, data, and improvement tools as appropriate, with support from project managers and data scientists. 
• Facilitates multidisciplinary workgroups, task forces, and committees focused on improving clinical quality, regulatory compliance, and patient outcomes. 
• Provides strategic direction to operational and clinical leaders regarding improvement priorities and implementation strategies. 
• Monitors initiative progress, evaluates effectiveness of interventions, and recommends modifications to ensure sustained improvement. 

Clinical Initiative Leadership

• Leads complex, organization-wide quality improvement initiatives from opportunity identification through implementation and sustainment. 

• Establishes initiative objectives, scope, priorities, timelines, success metrics, and governance structures in collaboration with executive and operational leadership. 
• Coordinates interdisciplinary stakeholders to achieve organizational quality and regulatory objectives. 
• Anticipates barriers to implementation and proactively develops mitigation strategies. 
• Provides regular updates to senior leadership regarding initiative progress, risks, outcomes, and recommendations. 
• Ensures improvement initiatives align with organizational strategic goals, patient safety priorities, CMS quality measures, and regulatory expectations. 
• Applies change management models and approaches to increase adoption and sustaining of change.

Clinical and Quality Analytics

• Collaborates with QI data scientists to guide detailed analysis of clinical documentation, quality measures, and healthcare data to identify performance gaps and opportunities for improvement. 

• Reviews medical records for compliance with CMS Core Measures, Conditions of Participation, accreditation standards, payer requirements, and organizational quality initiatives. 
• Collaborates with clinical leaders and data analysts to validate findings and interpret quality performance metrics. 
• Guides the development of meaningful reports, dashboards, visualizations, and executive summaries that communicate findings and support decision making. 
• Identifies clinical trends and emerging risks requiring organizational attention. 
• Assesses the impact of improvement initiatives through ongoing monitoring of quality outcomes, process measures, balancing measures, and regulatory performance. 

 Clinical Consultation

• Serves as an internal consultant to clinical and operational leadership regarding quality improvement opportunities identified through medical record review, quality analytics, and regulatory assessment. 

• Provides expert guidance on interpretation of CMS measures, clinical quality indicators, documentation standards, and regulatory expectations. 
• Partners with leaders to develop action plans that address identified performance gaps and improve patient outcomes. 
• Supports departments in selecting and applying appropriate quality improvement methodologies and tools to achieve desired outcomes. 
• Promotes evidence-based practice and standardization across the organization. 

Regulatory & Accreditation Support

• Maintains expert knowledge of CMS quality measures, Conditions of Participation, Joint Commission standards, and other applicable regulatory requirements. 
• Leads regulatory readiness initiatives related to assigned quality measures and clinical performance indicators. 
• Supports organizational preparation for accreditation and regulatory surveys through targeted chart review, gap assessment, and improvement planning. 
• Collaborates with compliance, quality, physician leadership, nursing leadership, and operational leaders to ensure ongoing regulatory compliance. 
• Monitors changes in federal, state, and accreditation requirements and evaluates organizational impact. 

Education and Subject Matter Expertise

• Serves as a subject matter expert in quality improvement methodologies, clinical quality measures, regulatory compliance, and performance improvement. 
• Provides education to leadership and clinical teams regarding findings, regulatory updates, quality trends, and evidence-based improvement strategies. 
• Assists QI Educator in development of organizational resources, tools, and best practices that strengthen quality improvement capabilities. 

Other duties as assigned.

MINIMUM EDUCATION & EXPERIENCE

• Bachelor's degree and 8 years of relevant experience required
• Master's degree preferred
• Or equivalent combination of education and experience
• 5 years clinical analysis and performance improvement preferred
• Minimum three (3) years leading multidisciplinary quality improvement or regulatory initiatives preferred. 

KNOWLEDGE, SKILLS AND ABILITIES

• Strong data analytic skills using Excel and other electronic tools required
• Experience with Epic Reporting Workbench and Dashboards and clinical workflow(s) required
• Strong data visualization skills utilizing Tableau preferred
• Demonstrated expertise in clinical documentation review, medical record abstraction, CMS quality measures, regulatory standards, and healthcare quality improvement preferred. 
• Experience interpreting healthcare quality data and leading organization-wide improvement initiatives preferred. 
• Strong knowledge of CMS quality programs, Joint Commission standards, Conditions of Participation, and evidence-based clinical practice preferred. 
• Excellent leadership, facilitation, communication, and relationship-building skills preferred

LICENSES AND CERTIFICATIONS

• Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Patient Safety (CPPS), or equivalent quality certification preferred.

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.