Clinical Quality and Compliance Specialist

Essential Job Functions

• Conducts Clinical and Compliance Audits: 20%
• Performs routine audits and reviews of medical, nursing, and behavioral health documentation to evaluate compliance with CMS Conditions of Participation, Joint Commission standards, Texas Administrative Code, DSHS policies, and other applicable regulatory requirements.
• Conducts medical record audits to assess the quality, accuracy, completeness, and timeliness of clinical documentation, patient care processes, and patient rights protections.
• Identifies compliance risks, documentation deficiencies, and opportunities for performance improvement; analyzes trends; prepares audit reports; develops recommendations; and collaborates with interdisciplinary teams to implement and monitor corrective action plans.
• Conducts follow-up audits to evaluate the effectiveness and sustainability of corrective actions and support continuous regulatory compliance and quality improvement.
• Led and Supports Human Rights Investigations: 20%
• Conducts investigations of patient safety events and patient rights concerns to determine compliance with applicable federal and state regulations, hospital policies, and standards of care.
• Serves as the designated investigator for allegations of abuse, neglect, exploitation, grievances, and other significant compliance matters.
• Counsels and supports interdisciplinary teams in resolving patient safety and rights issues.
• Prepares investigative reports, develops recommendations, and collaborates with Quality Management, Risk Management, Hospital Administration, and interdisciplinary teams to ensure timely resolution, corrective action, and regulatory compliance.
• Maintains monitoring of investigation outcomes and patient grievances to identify trends, evaluate systemic risks, and recommend quality improvement initiatives.

Knowledge, Skills and Abilities (KSAs)

• Knowledge:
• Federal and state healthcare regulations, including CMS Conditions of Participation, Joint Commission standards, Texas Administrative Code, and DSHS policies.
• Principles of healthcare quality improvement, regulatory compliance, patient safety, and clinical documentation.
• Patient rights, abuse, neglect, exploitation investigations, and grievance processes.
• Quality improvement methodologies, including Plan Do Study Act, Root Cause Analysis, Failure Mode and Effects Analysis, and Lean principles.
• Electronic Medical Record (EMR) systems, medical record auditing, and documentation standards.
• Performance measurement, data analysis, dashboard development, and quality reporting.
• Behavioral health and medical terminology sufficient to evaluate clinical documentation and patient care.
• Ethical principles related to privacy, informed consent, trauma-informed care, and confidentiality.
• Quality governance, committee operations, and organizational performance improvement.

• Skills:
• Conducting medical record reviews, compliance audits, and clinical documentation assessments.
• Interviewing staff and patients and conducting fact-finding investigations.
• Identifying regulatory risks, analyzing data and trends, and developing corrective actions.
• Interpreting and communicating regulatory, accreditation, and clinical requirements.
• Applying critical thinking, problem-solving, and quality improvement methodologies.
• Using electronic medical record (EMR) systems and data analytics to support audits, investigations, and performance reporting.
• Preparing reports, dashboards, presentations, and performance indicators for leadership and quality committees.
• Facilitating interdisciplinary meetings, quality committees, and staff education.
• Building collaborative relationships while managing confidential information in accordance with applicable laws and policies.

• Abilities:
• Interpret and apply federal, state, and accreditation requirements related to healthcare quality, patient safety, and patient rights.
• Evaluate clinical documentation for accuracy, completeness, and compliance with standards of care.
• Conduct objective investigations, analyze findings, and develop recommendations for corrective action.
• Communicate effectively with clinical, administrative, and leadership teams.
• Coordinate multiple quality improvement, regulatory compliance, and accreditation initiatives simultaneously.
• Present quality and compliance information to leadership and interdisciplinary committees.
• Translate regulatory requirements into operational improvements and quality initiatives.
• Build collaborative relationships across multidisciplinary teams while exercising independent judgment.
• Adapt to changing regulatory requirements and organizational priorities.

Initial Screening Criteria

• Graduation from an accredited four year college or university with a bachelors degree in nursing, public health, healthcare administration, social work, behavioral health, health sciences, or another related healthcare field; OR graduation from an accredited vocational nursing program (LVN).
• At least four (4) years of progressively responsible experience in healthcare quality management, regulatory compliance, accreditation, patient safety, clinical documentation review, medical record auditing, investigations, or performance improvement in a healthcare setting.
• Experience reviewing clinical documentation, conducting audits or investigations, and using electronic medical record (EMR) systems.