Medical Staff Clinical Quality Specialist

Nashville General Hospital•Nashville, TN

5d•Onsite

About The Position

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.

Requirements

Bachelor's degree in nursing, Healthcare Administration, Health Information Management, or a related healthcare field required.
Bachelor of Science in Nursing (BSN) required.
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.
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

Nice To Haves

Active Registered Nurse (RN) license preferred.
Certified Professional Medical Services Management (CPMSM)
Certified Professional in Healthcare Quality (CPHQ)

Responsibilities

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

Benefits

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