Clinical Quality Specialist

Crossing Rivers Health•Prairie du Chien, WI

About The Position

The Clinical Quality Specialist reports to the Chief Clinical Officer and is responsible for clinical quality data abstraction, chart review, and patient safety surveillance with a primary focus on Inpatient Services due to regulatory reporting requirements. This role supports hospital-wide quality and patient safety activities through data analysis, monitoring, and regulatory readiness, with an emphasis on accurate reporting, trend identification, and proactive risk detection. This position is data-driven and execution-focused, providing data, findings, and patient safety insights to leadership and the Quality Coordinator, while supporting compliance with CMS Conditions of Participation and Joint Commission standards.

Requirements

Associate’s Degree (two-year college or technical school) Required, Field of Study: Nursing
Knowledge of CMS Conditions of Participation and Joint Commission standards
Strong analytical and data interpretation skills
High attention to detail and accuracy
Previous experience in quality, patient safety, or regulatory roles
Knowledge of Federal, State, and local laws and regulations as they pertain to healthcare
Microsoft Office
Registered Nurse (RN) license, active and in good standing: Required.

Nice To Haves

Bachelor’s Degree (four-year college) Preferred, Field of Study: Nursing
Familiarity with quality reporting systems and EHR abstraction tools

Responsibilities

Abstracts clinical quality data in accordance with CMS, Joint Commission, and other regulatory requirements.
Conducts chart reviews to ensure compliance with clinical standards, policies, and regulatory expectations.
Ensures accuracy, completeness, and timeliness of abstracted data.
Supports validation of quality data and resolves discrepancies.
Maintains knowledge of abstraction specifications and regulatory updates.
Monitors inpatient quality and patient safety indicators, including but not limited to : Falls; Pressure injuries; Infection prevention measures; Readmissions.
Conducts focused chart reviews related to adverse events and near misses.
Identifies trends, patterns, and potential patient safety risks.
Supports root cause analysis and follow-up from a data and documentation perspective.
Supports CMS and Joint Commission survey readiness through: Ongoing chart audits; Tracer preparation and participation; Policy and documentation compliance reviews; Assisting with regulatory audits by providing requested data and chart findings; Maintains current knowledge of applicable regulations and accreditation standards.
Works closely with the Quality Coordinator to ensure alignment between data abstraction, reporting, and quality outcomes.
Communicates data findings and patient safety concerns to the CCO, Director of Inpatient Services, and appropriate leaders.
Collaborates with department leaders across the hospital to support data requests and patient safety monitoring.
Provides quality data abstraction and chart review support to non-inpatient departments as assigned.
Supports hospital-wide patient safety initiatives through data analysis and monitoring.
Participates in quality and patient safety committees as assigned.
Maintains knowledge of applicable laws, regulations, and standards.
Ensures adherence to Crossing Rivers Health policies and procedures.
Identifies problems and develops appropriate solutions.
Performs additional responsibilities as assigned to meet patient, department, and organizational needs.