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.