Clinical Quality and Compliance Specialist

Department of Public Safety • San Antonio, TX

5d • Onsite

About The Position

The Clinical Quality and Compliance Specialist perform advanced clinical compliance and patient rights oversight work within the Quality Management Department. The position conducts medical record audits, leads patient safety and human rights investigations, and provides consultative guidance to ensure compliance with CMS Conditions of Participation, Joint Commission standards, and Texas Administrative Code requirements.

Requirements

• 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.
• Knowledge of Federal and state healthcare regulations, including CMS Conditions of Participation, Joint Commission standards, Texas Administrative Code, and DSHS policies.
• Knowledge of Principles of healthcare quality improvement, regulatory compliance, patient safety, and clinical documentation.
• Knowledge of Patient rights, abuse, neglect, exploitation investigations, and grievance processes.
• Knowledge of Quality improvement methodologies, including Plan Do Study Act, Root Cause Analysis, Failure Mode and Effects Analysis, and Lean principles.
• Knowledge of Electronic Medical Record (EMR) systems, medical record auditing, and documentation standards.
• Knowledge of Performance measurement, data analysis, dashboard development, and quality reporting.
• Knowledge of Behavioral health and medical terminology sufficient to evaluate clinical documentation and patient care.
• Knowledge of Ethical principles related to privacy, informed consent, trauma-informed care, and confidentiality.
• Knowledge of Quality governance, committee operations, and organizational performance improvement.
• Skills in Conducting medical record reviews, compliance audits, and clinical documentation assessments.
• Skills in Interviewing staff and patients and conducting fact-finding investigations.
• Skills in Identifying regulatory risks, analyzing data and trends, and developing corrective actions.
• Skills in Interpreting and communicating regulatory, accreditation, and clinical requirements.
• Skills in Applying critical thinking, problem-solving, and quality improvement methodologies.
• Skills in Using electronic medical record (EMR) systems and data analytics to support audits, investigations, and performance reporting.
• Skills in Preparing reports, dashboards, presentations, and performance indicators for leadership and quality committees.
• Skills in Facilitating interdisciplinary meetings, quality committees, and staff education.
• Skills in Building collaborative relationships while managing confidential information in accordance with applicable laws and policies.
• Abilities to Interpret and apply federal, state, and accreditation requirements related to healthcare quality, patient safety, and patient rights.
• Abilities to Evaluate clinical documentation for accuracy, completeness, and compliance with standards of care.
• Abilities to Conduct objective investigations, analyze findings, and develop recommendations for corrective action.
• Abilities to Communicate effectively with clinical, administrative, and leadership teams.
• Abilities to Coordinate multiple quality improvement, regulatory compliance, and accreditation initiatives simultaneously.
• Abilities to Present quality and compliance information to leadership and interdisciplinary committees.
• Abilities to Translate regulatory requirements into operational improvements and quality initiatives.
• Abilities to Build collaborative relationships across multidisciplinary teams while exercising independent judgment.
• Abilities to Adapt to changing regulatory requirements and organizational priorities.

Nice To Haves

• Experience with CMS Conditions of Participation, Joint Commission standards, or other healthcare regulatory requirements.
• Experience conducting patient rights investigations and supporting accreditation or regulatory surveys.
• Experience preparing quality reports, dashboards, performance indicators, or committee presentations.
• Experience working in a hospital, long-term care, behavioral health, or public health setting.

Responsibilities

• Conducts Clinical and Compliance Audits: 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.
• Leads and Supports Human Rights Investigations: 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.
• Conducts fact-finding interviews, medical record reviews, and policy analyses consistent with Texas Administrative Code and other regulatory requirements.
• 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.
• Monitors investigation outcomes and patient grievances to identify trends, evaluate systemic risks, and recommend quality improvement initiatives.
• Provides Clinical Consultation and Technical Assistance: Serves as a subject matter expert on regulatory compliance, patient rights, accreditation standards, quality improvement, and clinical documentation.
• Provides consultation and technical assistance to leadership and interdisciplinary teams regarding regulatory requirements, documentation standards, patient rights, and quality improvement initiatives.
• Participates in interdisciplinary meetings to support admissions, treatment planning, care coordination, discharge planning, and organizational compliance.
• Develops and Delivers Training and Education: Designs and facilitates staff training on patient rights, human rights investigations, documentation standards, trauma-informed practices, and regulatory compliance.
• Provides orientation and ongoing education to new and existing staff to promote a rights-based culture of care and readiness for CMS and Joint Commission surveys.
• In addition to staff education, ensures patients receive accessible, trauma-informed education on their rights and responsibilities at admission and throughout their care.
• Coordinates Quality Programs and Committees: Coordinates and facilitates agency-wide quality governance activities, including the Governing Body, Quality Management Committee, Medical Executive Committee, and other interdisciplinary committees.
• Prepares meeting agendas, executive dashboards, quality reports, committee presentations, regulatory updates, and meeting minutes.
• Tracks committee recommendations and collaborates with departments to support continuous quality improvement, patient safety, accreditation readiness, and regulatory compliance.
• Accreditation and Regulatory Readiness: Prepares accurate and timely reports of audits, investigations, and compliance activities while ensuring documentation meets regulatory and confidentiality requirements.
• Coordinates accreditation and regulatory readiness activities by conducting mock tracers, regulatory rounds, environmental assessments, and interdisciplinary patient tracers.
• Collaborates with departments to support continuous compliance with CMS, Joint Commission, DSHS, and other applicable regulatory standards and assists during accreditation and regulatory surveys.
• Educates and Informs Patients About Rights: Ensures patients are informed of their rights in accordance with CMS §482.13 and Joint Commission RI.01.01.01.
• Provides individualized and group education on patient rights, privacy, grievance procedures, and access to advocacy services.
• Collaborates with interdisciplinary teams to reinforce patients’ understanding of their rights throughout treatment and hospitalization, ensuring information is accessible, trauma-informed, and culturally responsive.
• Leads Performance Improvement Projects: Leads and participates in performance improvement initiatives using evidence-based quality improvement methodologies, including Plan-Do-Study-Act (PDSA), Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and Lean principles.
• Reviews, develops, and revises hospital policies and procedures to support regulatory compliance, accreditation readiness, and organizational performance improvement.
• Participates in special projects, committees, and other duties as assigned.

Benefits

• insurance coverage and other benefits available through the State of Texas Group Benefits Plan administered by the Employee Retirement System of Texas (ERS)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level