Full-Time
Lead Quality Improvement Specialist
Updated on 8/1/2026
University of Rochester
Compensation Overview
$95.7k - $143.5k/yr
Rochester, NY, USA
In Person
Category
 Medical, Clinical & Veterinary (1) |
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Required Skills
Data Visualization
Tableau
Data Analysis
Excel/Numbers/Sheets
Requirements
- A Bachelor's degree and eight years of relevant experience are required, or an equivalent combination of education and experience.
- Strong data analytic skills using Excel and other electronic tools are required.
- Experience with Epic Reporting Workbench, Dashboards, and clinical workflows is required.
Responsibilities
- Serve as the clinical quality and safety expert for assigned organizational initiatives.
- Conduct comprehensive clinical reviews of medical records to evaluate documentation accuracy and collaborate with clinical documentation integrity and coding leaders to ensure regulatory compliance.
- Review medical records to evaluate quality-of-care opportunities and adherence to evidence-based practice.
- Perform detailed chart reviews related to CMS quality measures, accreditation standards, patient safety initiatives, and other internal and external quality programs.
- Identify trends, variations, documentation gaps, compliance risks, and clinical improvement opportunities.
- Interpret clinical findings and translate complex regulatory requirements into actionable recommendations for operational and physician leadership.
- Partner with physicians, nursing leadership, advanced practice providers, and interdisciplinary teams to improve clinical quality, safety, and documentation practices.
- Lead enterprise quality improvement initiatives resulting from chart review findings, quality performance data, regulatory requirements, patient safety events, and organizational priorities.
- Develop improvement strategies using Continuous Quality Improvement methodology, data, and improvement tools, with support from project managers and data scientists.
- Facilitate multidisciplinary workgroups, task forces, and committees focused on clinical quality, regulatory compliance, and patient outcomes.
- Provide strategic direction to operational and clinical leaders regarding improvement priorities and implementation strategies.
- Monitor initiative progress, evaluate intervention effectiveness, and recommend modifications to ensure sustained improvement.
- Lead complex, organization-wide quality improvement initiatives from opportunity identification through implementation and sustainment.
- Establish initiative objectives, scope, priorities, timelines, success metrics, and governance structures in collaboration with executive and operational leadership.
- Coordinate interdisciplinary stakeholders to achieve organizational quality and regulatory objectives.
- Anticipate implementation barriers and proactively develop mitigation strategies.
- Provide regular updates to senior leadership regarding initiative progress, risks, outcomes, and recommendations.
- Ensure improvement initiatives align with organizational strategic goals, patient safety priorities, CMS quality measures, and regulatory expectations.
- Apply change management models and approaches to increase adoption and sustain change.
- Collaborate with quality improvement data scientists to guide detailed analysis of clinical documentation, quality measures, and healthcare data to identify performance gaps and improvement opportunities.
- Review medical records for compliance with CMS Core Measures, Conditions of Participation, accreditation standards, payer requirements, and organizational quality initiatives.
- Collaborate with clinical leaders and data analysts to validate findings and interpret quality performance metrics.
- Guide the development of reports, dashboards, visualizations, and executive summaries that communicate findings and support decision-making.
- Identify clinical trends and emerging risks requiring organizational attention.
- Assess the impact of improvement initiatives through ongoing monitoring of quality outcomes, process measures, balancing measures, and regulatory performance.
- Serve as an internal consultant to clinical and operational leadership regarding quality improvement opportunities identified through medical record review, quality analytics, and regulatory assessment.
- Provide expert guidance on CMS measures, clinical quality indicators, documentation standards, and regulatory expectations.
- Partner with leaders to develop action plans that address performance gaps and improve patient outcomes.
- Support departments in selecting and applying appropriate quality improvement methodologies and tools to achieve desired outcomes.
- Promote evidence-based practice and standardization across the organization.
- Maintain expert knowledge of CMS quality measures, Conditions of Participation, Joint Commission standards, and other applicable regulatory requirements.
- Lead regulatory readiness initiatives related to assigned quality measures and clinical performance indicators.
- Support organizational preparation for accreditation and regulatory surveys through targeted chart review, gap assessment, and improvement planning.
- Collaborate with compliance, quality, physician leadership, nursing leadership, and operational leaders to ensure ongoing regulatory compliance.
- Monitor changes in federal, state, and accreditation requirements and evaluate organizational impact.
- Serve as a subject matter expert in quality improvement methodologies, clinical quality measures, regulatory compliance, and performance improvement.
- Provide education to leadership and clinical teams regarding findings, regulatory updates, quality trends, and evidence-based improvement strategies.
- Assist the quality improvement educator in developing organizational resources, tools, and best practices that strengthen quality improvement capabilities.
- Perform other duties as assigned.
Desired Qualifications
- A Master's degree is preferred.
- Five years of clinical analysis and performance improvement experience is preferred.
- At least three years of leading multidisciplinary quality improvement or regulatory initiatives is preferred.
- Strong data visualization skills using Tableau are preferred.
- Expertise in clinical documentation review, medical record abstraction, CMS quality measures, regulatory standards, and healthcare quality improvement is preferred.
- Experience interpreting healthcare quality data and leading organization-wide improvement initiatives is preferred.
- Strong knowledge of CMS quality programs, Joint Commission standards, Conditions of Participation, and evidence-based clinical practice is preferred.
- Excellent leadership, facilitation, communication, and relationship-building skills are preferred.
- A Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, or equivalent quality certification is preferred.