Performance Improvement Coordinator - Full Time with Benefits

General Summary:

This position performs review of patient records for quality of patient care and identifies, analyzes and implements performance improvement activities.  Collaborates with teams to actively initiate, develop, and monitor quality indicators and facilitate performance improvement opportunities. Performs retrospective and concurrent review of records to meet the requirements for all National Hospital Inpatient Quality Measures and organizational strategic goals. Experience with Joint Commission Core Measures, CMS Scope of Work, NDNQI, ACS MBSAQIP and/or NSQIP, VON, and/or GWTG Stroke, ACS and Heart Failure strongly preferred. Supports the Medical Peer Review process through use of the Event Reporting System. Assists hospital staff to remain in a state of constant readiness for a Joint Commission accreditation survey. Novice to Expert in Quality/Performance Improvement processes and methodologies.

Minimum Knowledge, Skills, & Abilities Required:

• Registered nurse from an accredited school of nursing or healthcare professional from an accredited school required with an active Maryland License or Compact State.


• Bachelor’s degree in nursing required.


• Three to five years of experience in either nursing in an acute care hospital (preferable in medical/surgical, emergency medicine, perioperative, or critical care) OR experience in Performance Improvement with knowledge of procedures, treatments and medications in those areas.


• Certification as a CPHQ strongly preferred but other certifications such as CPPS or HCAP considered


• Previous experience in performance improvement is desirable but not required.


• Lean Six Sigma experience or certification is preferred.


• Strong clinical knowledge and critical thinking skill to evaluate appropriateness of clinical practice, including diagnosis, treatment and surgical procedures for varieties of disease and disorders.


• Excellent communication skills, both verbal and written.


• Strong organizational skills and ability to prioritize and manage multiple tasks.


• Interacts with physicians, nurses, department leadership and others while identifying quality of care issues.


• Applies creative problem solving, identifies errors of omission, and utilizes resources effectively.


• Knowledge of computer software and able to complete data entry from PC database applications. Novice to Expert experience using Microsoft Excel, PowerPoint, SharePoint, Teams preferred.  


• Works professionally with a diverse population base.


• Maintains a high level of confidentiality.

Caring for you as you care for the CommUNITY
Frederick Health offers a comprehensive and affordable benefits package. Health, Dental and Vision insurance are offered the 1st of the month after 30 days of employment to all employees hired to work at least 20 hours per week and we offer multiple plans to best meet your and your family's needs. Life insurance, Short-Term Income Replacement and Long-Term Disability are employer paid for eligible employees. Frederick Health offers a robust Paid Time Off program for eligible employees. Our 403B retirement plan helps you save for your retirement and includes an employer match to eligible employees. All employees have access to free financial planning sessions. We also offer an educational assistance program to support your education goals as well as an employer paid Employee Assistance Program. 

Pay is based on experience, skills and education.   If position is part-time, salary will be pro-rated based on scheduled hours.  The pay range may also vary within the stated range based on specialty if applicable. Non-Exempt positions may have shift differential and/or Overtime paid, if applicable.

Salary Range: $69,908.80 - $100,131.20

Hours: Monday-Friday day hours with some early or late meetings.