The Senior Performance Improvement (PI) Analyst is responsible for developing, implementing, and maintaining performance improvement processes related to medical staff peer reviews, credentialing, and regulatory compliance. This role collaborates with physicians, hospital leadership, and quality teams to enhance patient safety, improve clinical outcomes, and ensure adherence to accreditation and regulatory standards. The Senior Analyst will utilize data analytics, process improvement methodologies, and stakeholder engagement to drive performance excellence and accountability within the medical staff. Essential Functions and Responsibilities include managing Medical Staff Performance & Peer Review Process, collaborating with Process Improvement Nurse to ensure compliance with accreditation requirements, integrating performance data into appointment and privileging processes, supporting Physician Quality Management Committee, designing information management systems for performance data, analyzing physician performance data, developing dashboards and reports, ensuring regulatory compliance, serving as subject matter expert during audits, conducting training sessions, leading interdisciplinary committees, assisting department leadership with budget and strategic planning, and providing mentorship. Qualifications require an active RN license, a Bachelor’s degree in healthcare or related field, minimum five years clinical nurse experience with at least two years in quality or performance improvement, proficiency in data analysis tools and credentialing systems, knowledge of TJC and CMS standards, and preferred certifications and software experience. Occasional travel may be required.
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