The Quality, Regulatory & Performance Improvement Registered Nurse (RN) supports the organization’s quality improvement, patient safety, regulatory compliance, data management, and continuous survey readiness activities. Working closely with the Director of Quality and organizational leaders, the RN coordinates quality and regulatory projects, supports corrective action plans, monitors ongoing compliance, and assists departments in improving processes and patient outcomes. 

The RN collects, abstracts, validates, analyzes, and presents clinical, quality, patient safety, and operational data to identify trends, measure performance, and support organizational decision-making. This position works across multiple clinical applications, regulatory portals, databases, vendor systems, and reporting platforms to ensure information is accurate, complete, and submitted within required timelines.

The RN supports and facilitates Root Cause Analyses, Failure Mode and Effects Analyses, process reviews,

performance improvement initiatives, regulatory audits, and Joint Commission survey readiness activities. This

position also coordinates required reporting and submissions to CMS, state agencies, The Joint Commission, and 

other regulatory bodies.

The RN serves as a resource to departments by translating data, quality standards, regulatory requirements, and 

performance findings into understandable reports, measurable action plans, and sustainable

improvements.

Essential Functions

Quality Data and Reporting

• Collects, abstracts, validates, analyzes, and reports clinical, patient safety, operational, regulatory, and performance improvement data from internal and external sources. 
• Develops and maintains Excel workbooks, trackers, dashboards, and data-validation tools. 
• Investigates data discrepancies, missing information, measure logic, and numerator or denominator issues and coordinates corrections with departments, Information Systems, and vendors. 
• Identifies trends, variation, risks, and improvement opportunities and presents findings to leaders, medical staff, committees, and the Board as assigned. 
• Maintains data definitions, source documentation, audit trails, and supporting evidence to ensure data integrity and reproducibility. 

Accreditation and continuous survey readiness

• Coordinates assigned Joint Commission survey readiness projects, tracers, audits, evidence collection, document control, action plans, and follow-up activities.
• Maintains organized and retrievable regulatory evidence, including policies, education records, monitoring results, meeting documentation, corrective actions, and sustainment data.
• Assists with mock surveys, onsite survey support, post-survey corrective action documentation, Evidence of Standards Compliance activities, and ongoing compliance monitoring.
• Partners with department leaders to translate standards and findings into practical work plans and verifies that corrective actions are completed, measured, and sustained.
• Supports readiness for CMS, state, accreditation, and other external reviews as assigned.

Performance Improvement and Patient Safety

• Supports and, when assigned, facilitates Root Cause Analyses, apparent cause analyses, FMEAs, PDSA cycles, process mapping, and other performance improvement activities. 
• Assists teams in identifying contributing factors and system causes and developing measurable corrective actions with assigned owners, completion dates, and effectiveness measures. 
• Tracks adverse events, quality indicators, improvement projects, corrective action plans, and patient outcomes. 
• Supports QAPI, patient safety, medical staff quality review, organizational quality goals, and other assigned improvement initiatives. 
• Partners with department leaders to translate standards, findings, and performance data into practical and sustainable improvements. 
• Protects confidential, peer review, patient safety, quality, and other privileged information in accordance with applicable laws and organizational policies. 

Collaboration and project coordination

• Builds effective working relationships with clinical and non-clinical departments, Information Systems, Health Information Management, Medical Staff Services, Finance, vendors, and senior leaders.
• Coordinates multiple concurrent projects and reporting cycles, establishes timelines and deliverables, follows up on outstanding items, and communicates barriers before deadlines are missed.
• Prepares accurate reports, presentations, committee materials, and educational resources for Quality, Safety, Performance Improvement, Medical Executive, Board, and other groups as assigned.
• Provides education and technical assistance regarding data collection, measure requirements, Excel tools, reporting workflows, and improvement methods.
• Performs other duties consistent with the purpose and level of the position.

Education & Training requirements

• Current New Mexico or multistate Registered Nurse license required.
• Bachelor’s degree in nursing, healthcare, quality, health information management, information systems, or a related field required preferred.
• Experience with CMS, state, and/or Joint Commission reporting and accreditation activities preferred.
• Experience using MEDITECH clinical applications or another electronic health record preferred.
• Quality or patient safety certification, such as CPHQ or CPPS, obtained within 2 years.

Work Experience Requirements

• Knowledge of Microsoft Excel, including formulas, sorting and filtering, conditional formatting, charts, pivot tables, lookups, data validation, and reconciliation of large or complex datasets.
• Ability to learn and work accurately in multiple software applications, reporting portals, databases, electronic health record modules, and vendor platforms.
• Knowledge of healthcare quality measures, regulatory reporting, accreditation standards, data abstraction, validation, and performance improvement methods.
• Ability to facilitate or support RCA and FMEA activities using a systems-based, nonpunitive approach.
• Strong critical thinking, attention to detail, organization, project coordination, written communication, and presentation skills.
• Ability to interpret technical specifications, standards, regulations, policies, and measure manuals and translate them into operational requirements.
• Ability to manage competing priorities and recurring deadlines with limited supervision while escalating risks appropriately.
• Ability to collaborate professionally with frontline caregivers, providers, leaders, vendors, and external agencies.
• Ability to maintain strict confidentiality and use sound judgment when handling sensitive clinical, quality, regulatory, and peer review information.