Medical Staff Clinical Quality Specialist

Description

Nashville General Hospital is looking to hire a Medical Staff Clinical Quality Specialist. 

The Medical Staff Clinical Quality Specialist supports the organization’s medical staff peer 

• review and professional practice evaluation processes to ensure quality patient care, regulatory 
• compliance, and provider accountability. This role coordinates clinical peer review activities, 
• maintains confidential records, assists medical staff committees, tracks performance 
• improvement actions and ensures compliance with accreditation and regulatory standards. The 
• role also coordinates and provides provider education to ensure compliance with medical staff 
• regulatory requirements.

Key Responsibilities

Clinical Peer Review Coordination

• Coordinate all aspects of the clinical peer review process, including case identification, physician referrals, data collection, and follow-up activities.
• Prepare peer review cases for committee review while maintaining strict confidentiality.
• Track Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) activities.
• Monitor physician action plans, corrective actions, and case resolutions.
• Maintain accurate peer review documentation and databases.

Medical Staff & Committee Support

• Coordinate medical staff quality committees and peer review meetings.
• Prepare meeting agendas, minutes, reports, and supporting documentation.
• Maintain confidential committee records in accordance with medical staff bylaws and hospital policies.
• Support physician leadership with quality initiatives and committee activities.

Healthcare Quality & Regulatory Compliance

• Ensure compliance with The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and state and federal healthcare regulations.
• Assist with accreditation surveys, audits, and quality reporting.
• Maintain documentation supporting credentialing, privileging, and regulatory requirements.
• Educate providers on peer review processes and quality standards.

Data Analysis & Reporting

• Collect, analyze, and report physician quality metrics and peer review data.
• Develop dashboards, trend analyses, and reports for leadership and medical staff committees.
• Monitor provider performance indicators and identify opportunities for continuous quality improvement.

Collaboration & Communication

• Serve as a liaison between physicians, nursing leadership, quality departments, and hospital administration.
• Respond to provider questions regarding peer review and quality processes.
• Collaborate with the Quality, Patient Safety, and Professional Excellence team to support organizational goals.

Additional Responsibilities

• Manage assigned quality improvement projects with minimal supervision.
• Participate in hospital committees, educational programs, and professional development activities.
• Perform other duties as assigned.

Qualifications

Education

• Bachelor's degree in nursing, Healthcare Administration, Health Information Management, or a related healthcare field required.
• Bachelor of Science in Nursing (BSN) required.
• Active Registered Nurse (RN) license preferred.

Experience

• Two to five years of experience in one or more of the following:
  • Medical Staff Services
  • Clinical Quality Improvement
  • Peer Review Coordination
  • Risk Management
  • Hospital Administration
• Acute care hospital experience strongly preferred.
• Experience working with physicians, medical staff leadership, and accreditation standards.

Required Knowledge & Skills

• Clinical Peer Review
• Medical Staff Services
• OPPE and FPPE
• Physician Quality Improvement
• Healthcare Quality Management
• Medical Staff Bylaws
• Credentialing and Privileging
• The Joint Commission (TJC)
• Centers for Medicare & Medicaid Services (CMS)
• Accreditation and Regulatory Compliance
• Risk Management
• Patient Safety
• Healthcare Analytics and Reporting
• Electronic Medical Records (EMR)
• Microsoft Office Suite
• Strong organizational, analytical, written, and verbal communication skills
• Ability to maintain strict confidentiality with sensitive provider information

Preferred Certifications

• Certified Professional Medical Services Management (CPMSM)
• Certified Professional in Healthcare Quality (CPHQ)

• Medical, Dental, and Vision Insurance within first 31 days of employment
• Programs to reduce share of deductible and total out-of-pocket expenses
• Metro Health Incentive Program - Access to high quality healthcare without incurring out-of-pocket expenses
• Short and Long-Term Disability - up to 60% of eligible weekly pay
• Life Insurance - Metro provides you with basic life and AD&D coverage equal to $50,000 ($32,500 if you are age 65 or older), at no cost to you.
• Retirement Plan - eligible up to IRS max limits and includes company contribution
• Shift and Weekend Differential Pay Offered on Nights and Weekends
• Tuition Reimbursement for employee and dependents
• 12 paid holidays - any holiday worked is another holiday banked
• Flexible Spending Accounts
• Free Parking for all employees

We are an E-Verify employer.

For more information, please click on the following links: E-Verify Participation Poster: English | Spanish E-Verify Right to Work Poster: English | Spanish