Clinical Quality Specialist | SQM | Full Time (On-Site)

The Clinical Quality Coordinator is a Bachelor of Science in Nursing (BSN)-prepared registered nurse responsible for supporting the organization's quality improvement, patient safety, regulatory compliance, and population health initiatives. This position reports directly to the Senior Director of Quality & Regulatory Affairs and plays a key operational role in the execution of clinical quality programs across hospital, ambulatory, rural health clinic, and community-based settings.

The Clinical Quality Coordinator assists with clinical chart reviews, data abstraction, regulatory compliance activities, clinical education, and quality improvement initiatives. This role supports Joint Commission readiness, CMS regulatory compliance, and ongoing performance improvement efforts by ensuring accurate clinical documentation review, identifying care gaps, and supporting frontline education and practice standardization.

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.
• Assist in 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.
• Assist in 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.
• Assist in maintaining Joint Commission readiness through ongoing chart reviews, tracer participation, and documentation audits.
• Support CMS regulatory compliance activities, including Conditions of Participation and other applicable standards.
• Participate in mock surveys, accreditation readiness activities, and follow-up corrective action processes.
• Help ensure documentation and clinical processes align with regulatory and accreditation requirements.
• Assist in the development and delivery of clinical education related to quality improvement, documentation standards, patient safety, and regulatory compliance.
• Provide frontline education and coaching to clinical staff regarding documentation best practices and quality measure requirements.
• Support onboarding education related to quality, safety, and regulatory expectations.
• Reinforce evidence-based practices and organizational clinical standards.
• Assist with care gap identification and closure activities in support of population health and value-based care programs.
• Support care management teams with tracking of high-risk patient populations.
• Contributes to initiatives aimed at improving preventive care, chronic disease management, and transitions of care.
• Work collaboratively with physicians, nurses, quality staff, care management, and regulatory teams to support organizational goals.
• Communicate findings from chart reviews and audits to the Senior Director of Quality & Regulatory Affairs.
• Participate in quality committees, work groups, and interdisciplinary improvement teams as assigned.

Job Requirements

Required Education

Bachelors of Science in Nursing (BSN)

Current Registered Nurse (RN) license in the state of practice

Required Work experience

• Minimum of 2-5 years of clinical nursing experience in hospital or ambulatory care settings preferred.
• Experience in quality improvement, case management, care coordination, or clinical documentation improvement is strongly preferred.
• Experience with Joint Commission standards, CMS regulations, or healthcare quality programs 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.
• Click or tap here to enter text.Click or tap here to enter text.

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.