Clinical Quality Specialist | SQM | Full Time

Job Duties And Responsibilities

• Conduct clinical chart reviews to support quality reporting, regulatory compliance, and performance improvement initiatives.
• Perform data abstraction and validation for quality metrics, including hospital, ambulatory, and value-based care measures.
• Identify documentation gaps, clinical variances, and opportunities for improvement based on evidence-based standards and regulatory requirements.
• Affiliate with monitoring quality dashboards, scorecards, and performance reports.
• Support implementation of quality improvement initiatives across inpatient and outpatient settings.
• Participate in root cause analyses, event reviews, and corrective action planning processes.
• Affiliate with tracking action items and ensuring completion of quality and safety improvement initiatives.
• Collaborate with interdisciplinary teams to support standardization of clinical processes and best practices.
• Affiliate with maintaining Joint Commission readiness through ongoing chart reviews, tracer participation, and documentation audits.
• Affiliate with supporting CMS regulatory compliance activities, including Conditions of Participation and other applicable standards.
• Affiliate with participating in mock surveys, accreditation readiness activities, and follow-up corrective action processes.
• Affiliate with helping ensure documentation and clinical processes align with regulatory and accreditation requirements.
• Affiliate with assisting in the development and delivery of clinical education related to quality improvement, documentation standards, patient safety, and regulatory compliance.
• Affiliate with assisting in frontline education and coaching to clinical staff regarding documentation best practices and quality measure requirements.
• Affiliate with supporting onboarding education related to quality, safety, and regulatory expectations.
• Affiliate with reinforcing evidence-based practices and organizational clinical standards.
• Affiliate with assisting with care gap identification and closure activities in support of population health and value-based care programs.
• Affiliate with supporting care management teams with tracking of high-risk patient populations.
• Affiliate with contributing to initiatives aimed at improving preventive care, chronic disease management, and transitions of care.
• Affiliate with working collaboratively with physicians, nurses, quality staff, care management, and regulatory teams to support organizational goals.
• Affiliate with communicating findings from chart reviews and audits to the Senior Director of Quality & Regulatory Affairs.
• Affiliate with participating in quality committees, work groups, and interdisciplinary improvement teams as assigned.

Job Requirements

• Required Education: Bachelors of Science in Nursing (BSN)
• Required Work Experience: Minimum of 2–5 years of clinical nursing experience in hospital or ambulatory care settings preferred.
• Required Knowledge, Skills, And Abilities: Strong clinical knowledge and understanding of evidence-based nursing practice; Familiarity with healthcare quality metrics, patient safety principles, and regulatory standards preferred; Ability to conduct detailed chart reviews and accurately abstract clinical data; Strong organizational skills and attention to detail; Effective communication and ability to provide clinical education and feedback; Ability to work collaboratively in a multidisciplinary environment; Proficiency with electronic health records (EHR) and basic data reporting tools.

Success Measures

• Accuracy and timeliness of clinical chart reviews and data abstraction.
• Contribution to successful Joint Commission and regulatory survey readiness.
• Support of quality improvement initiatives and completion of assigned action items.
• Identification and closure of clinical documentation and care gaps.
• Effectiveness in supporting clinical education and staff engagement.
• Contribution to improved quality metrics across hospital and ambulatory settings.

Organizational Expectations

• Provides a positive and professional representation of the organization.
• Promotes a culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.
• Maintains hospital standards for a clean and quiet environment.
• Maintains competency and knowledge of current standards of practice, trends, and developments in related scope-of-practice or job role.
• Participates in ongoing quality improvement activities.
• Maintains compliance with organization’s policies, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards.
• Complies with organizational and regulatory policies for handling confidential information.
• Demonstrates excellent customer service through their attitude and actions, consistent with the standards contained in The Gritman Way.