Clinical Quality Data Analyst

This role serves as the primary analytics partner for the Quality Department, collaborating with clinical leadership, operational teams, physicians, and executive leadership to develop meaningful reports, dashboards, and performance metrics that support quality improvement, patient safety, accreditation, and value-based care programs.

The Clinical Quality Data Analyst manages the collection, validation, analysis, visualization, and reporting of clinical quality data while ensuring compliance with Centers for Medicare & Medicaid Services (CMS), The Joint Commission, state regulatory agencies, and other external reporting requirements. This position leverages healthcare information systems and business intelligence tools to identify performance trends, monitor quality measures, support regulatory reporting, and provide data-driven recommendations that improve clinical outcomes, operational performance, and financial stewardship.

This position is based on-site at Nashville General Hospital. Candidates must reside within the Nashville Metropolitan area.

Essential Duties and Responsibilities

Clinical Quality Data Analytics

• Collect, extract, validate, analyze, and interpret clinical, operational, and quality data from electronic health records (EHR), quality reporting applications, and other healthcare information systems.
• Develop, maintain, and automate dashboards, scorecards, key performance indicators (KPIs), and executive reports supporting organizational quality goals.
• Perform statistical analysis, trend analysis, benchmarking, and predictive analysis to identify opportunities for quality improvement and performance optimization.
• Maintain data dictionaries, measure specifications, reporting methodologies, benchmarks, and business rules supporting quality measurement programs.
• Ensure data integrity, consistency, completeness, and accuracy through routine auditing, validation, reconciliation, and quality assurance processes.
• Develop standardized reporting tools and templates to improve consistency and accessibility of quality data across the organization.
• Provide analytical support for inpatient, outpatient, ambulatory, and specialty clinical programs.

Quality Measurement & Regulatory Reporting

• Coordinate the collection, validation, and submission of CMS Inpatient Quality Reporting (IQR), Outpatient Quality Reporting (OQR), Electronic Clinical Quality Measures (eCQMs), and other required regulatory reporting programs.
• Support reporting requirements for CMS, The Joint Commission (ORYX), Leapfrog, state agencies, and additional accreditation or regulatory organizations.
• Maintain current knowledge of CMS Hospital Quality Reporting (HQR), value-based purchasing, Hospital Readmissions Reduction Program (HRRP), Hospital-Acquired Condition (HAC) Reduction Program, and other quality reporting initiatives.
• Monitor reporting timelines to ensure timely, complete, and accurate submission of all required quality data.
• Collaborate with clinical departments to resolve documentation, abstraction, and data quality issues impacting regulatory reporting.

 

 

Performance Improvement & Patient Safety

• Partner with multidisciplinary performance improvement teams to identify opportunities that improve quality, patient safety, regulatory compliance, and operational efficiency.
• Conduct root cause analyses, variation analyses, and performance trend evaluations to identify opportunities for sustainable improvement.
• Evaluate quality initiatives by measuring outcomes, monitoring KPIs, and assessing the effectiveness of process improvement efforts.
• Analyze patient experience, patient safety, infection prevention, mortality, readmissions, and other clinical outcome data to support organizational improvement initiatives.
• Assist leadership in establishing performance targets and monitoring progress toward organizational quality goals.
• Support value-based care and population health initiatives through ongoing measurement and analysis of clinical performance indicators.

Data Visualization & Executive Reporting

• Design clear, visually compelling dashboards and reports that communicate complex clinical information to diverse audiences.
• Prepare executive-level presentations highlighting quality performance, regulatory compliance, organizational benchmarks, and improvement initiatives.
• Translate analytical findings into meaningful recommendations for physicians, nursing leadership, quality committees, and executive leadership.
• Establish visualization standards and reporting methodologies that promote consistent interpretation of quality performance throughout the organization.

Business Intelligence & Analytics Support

• Serve as a subject matter expert for healthcare analytics applications, reporting platforms, and business intelligence tools.
• Provide consultation and support to clinical departments regarding quality data interpretation, reporting methodologies, and performance metrics.
• Identify opportunities to improve reporting efficiency through automation, process improvement, and advanced analytics.
• Maintain proficiency in healthcare information systems, business intelligence applications, and emerging healthcare analytics technologies.

Additional Responsibilities

• Independently manage multiple projects while meeting established deadlines and organizational priorities.
• Participate on multidisciplinary committees, quality councils, patient safety teams, and organizational workgroups.
• Support strategic organizational initiatives through advanced analytics and performance measurement.
• Maintain current knowledge of healthcare quality measures, regulatory requirements, accreditation standards, and healthcare analytics best practices through continuing education and professional development.
• Perform other duties as assigned.

Minimum Qualifications

Education

• Bachelor's degree in Healthcare Informatics, Health Information Management, Nursing, Public Health, Health Administration, Clinical Sciences, Occupational Therapy, Physical Therapy, Pharmacy, or another healthcare-related discipline required.
• Equivalent combinations of education, training, and relevant healthcare analytics experience may be considered.

Experience

• Minimum three (3) years of experience in healthcare analytics, clinical quality, quality improvement, healthcare informatics, or healthcare business intelligence preferred.
• Experience with CMS quality reporting, accreditation standards, performance improvement, or regulatory reporting strongly preferred.
• Experience working with electronic health records (Cerner, Epic, or comparable EHR platforms) and healthcare reporting systems.
• Experience extracting, validating, analyzing, interpreting, and presenting clinical quality data.
• Experience supporting value-based purchasing, quality improvement initiatives, and accreditation activities preferred.

Knowledge, Skills, and Abilities

• Strong analytical, critical thinking, and problem-solving skills.
• Advanced proficiency with Microsoft Excel, including Power Query, Pivot Tables, Power Pivot, advanced formulas, and data modeling.
• Experience developing interactive dashboards using Tableau, Microsoft Power BI, Cerner HealtheIntent, Epic Reporting Workbench, Crystal Reports, or similar business intelligence platforms.
• Working knowledge of SQL, relational databases, healthcare data warehouses, statistical analysis, and data visualization principles preferred.
• Familiarity with Minitab, SPSS, SAS, R, Python, or other statistical software preferred.
• Knowledge of CMS quality measures, eCQMs, HEDIS, Joint Commission standards, Core Measures, Leapfrog, patient safety indicators, and value-based reimbursement programs.
• Knowledge of healthcare quality improvement methodologies including Lean, Six Sigma, PDSA, and Root Cause Analysis.
• Strong understanding of healthcare data governance, data quality management, and regulatory reporting requirements.
• Excellent written, verbal, and presentation skills with the ability to communicate technical information to clinical and executive audiences.
• Ability to manage multiple priorities while maintaining exceptional attention to detail and accuracy.

Preferred Certifications

• Certified Professional in Healthcare Quality (CPHQ)
• Certified Health Data Analyst (CHDA)
• Microsoft Power BI Data Analyst Associate
• Tableau Desktop Specialist or Tableau Certified Data Analyst
• Epic, Cerner, or other healthcare analytics certification
• Lean Six Sigma Green Belt or higher

Equivalent education, training, or demonstrated experience may be considered in lieu of certification.

Benefits:

• Competitive salary and benefits package
• Health, dental, and vision insurance
• Metro Health Incentive Program - Access to high quality healthcare without incurring out-of-pocket expenses
• Paid time off and continuing education opportunities
• 12 paid holidays
• Supportive and collaborative work environment