1+ months


Universal Health Services
Laredo, TX 78041
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The Quality Improvement/Core Measures Analyst is responsible for monitoring and analyzing quality, performance, and risk data; completes data abstraction; collection, reporting and data trending for each Core Measure under the direction of the Director of Quality and Performance Improvement.


1. Processes quality referrals through MIDAS when assigned.

2. Conducts timely and accurate medical record reviews and closed reviews for Core Measures patients, completes software processing related to reviews as assigned by Director.

3. Reports on the status of survey compliance, survey readiness, participates in department meetings and hospital wide skills fairs, etc.

4. Collects, analyzes, and aggregates data relating to quality reviews and Core Measures, assists with preparation of monthly Core Measures reports for PI Council and reports to appropriate committees as assigned by the Director.

5. Trends and Reports non-compliance on a concurrent basis to Lead Core Measure Analyst and or department Director.

6. Coordinates PI team Committees, and acts as a facilitator, as assigned by Director.

7. Oversees the completion, and submission of the Annual TJC PPR by working with unit/department managers,

Works with medical staff when applicable about recommended guidelines regarding Core Measure compliance.

8. Monitors TJC survey readiness activities, attends Corporate Conference Calls and webinars, related to Core Measures or other information deemed necessary, and reports findings to the Director and PI teams.

9. Schedules, coordinates, monitors, and reports survey readiness tracers.

10. Assists with policy development/updates for survey readiness.

11. Gathers and reports OPPE/FPPE/Peer Review data to Quality Director timely.

Job Requirements


  • Licensed Registered Nurse in the State of Texas is required.
  • One or more years experience in Acute care hospital setting, QI/OPPE/FPPE/Peer Review preferred.
  • Knowledge of and ability to create statistical PI tools/reports, and Core Measure indicators preferred.
  • Must be computer literate e.g. Word, Excel, Power Point, Windows based programs, WebEx, and knowledge to create statistical/trending reports.
  • Good communication skills required with public speaking preferred.
  • BLS certification required.
Posted: 2020-01-07 Expires: 2020-04-02

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Universal Health Services
Laredo, TX 78041

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