Summary: This position reports to the Director of Quality and Performance Improvement and up through the Vice President of Quality, Risk, Performance Improvement and Infection Control. This individual will conduct studies and analyze data to evaluate the performance in quality improvement, develop and implement activities to increase compliance rates as measured by nationally standardized benchmarks and definitions. Lead and participate in special projects as directed and perform other duties as assigned. This candidate will be responsible for various duties associated with the continuous monitoring, maintenance, and improvement of quality throughout the organization. Must have a valid Driver License Education: Bachelor's Degree in a HealthCare related field or equivalent experience in Quality and Performance Improvement, Joint Commission and CMS principles and methodology knowledge required. Bachelor prepared Registered Nurse or Master’s Degree level Preferred. Minimum experience Five (5) years. Skills and Abilities: Must be fluent in English and can communicate effectively across multiple departments and disciplines. Capability of following direction and guidance, able to work collaboratively with in a Team. Working knowledge of and proficiency in the use of Windows based PC system including Microsoft Outlook, Word, Excel Access and PowerPoint. Ability to plan, organize and lead data collection and the ability to navigate and evaluate medical records/ EMR. Ability to work independently and solve problems with the willingness to arch up issues to leadership when needed using the chain of command. Proven team leading skills including facilitating meetings, taking minutes, and tracking progress, and prioritizing tasks and deadlines. Must have a valid Driver License, transportation, and the willingness to travel to different facility locations as needed.