Clinical Quality Specialist

GENERAL DESCRIPTION The Clinical Quality Specialist is responsible for reviewing and evaluating quality of care concerns, including complaints, internal referrals, CTMs, appeal reconsiderations, and Hospital-Acquired Conditions (HACs). Ensures timely case resolution, oversight of Corrective Action Plans (CAPs), compliance with CMS and ASES requirements, and ongoing collaboration with providers and hospital quality teams to support quality outcomes and regulatory compliance. ESSENTIAL FUNCTIONS •Receives and reviews cases referred by the Grievance and Appeal Unit and other MCS departments, identifies GMP Providers and/or Administrators to be oriented or evaluated when a quality-of-care issue occurs. •Develop a work plan where the activities to be carried out during the week are evidenced, including the coordination for the individual discussions of the cases. •Liaison between the Quality Department and the Clinical Affairs teams, Grievance and Appeal units, to review, analyze, and determine complaints and quality of care issues in compliance with established standards. •Informs the Grievance and Appeal Unit of the list of necessary files and documentation required as part of the investigation process, in compliance with the times required in policy and procedure; and offers continuity of cases until their closure. •Conducts nursing-level case file evaluations, documents assessment progress in electronic applications within established timeframes, and collaborates with the reviewing physician in case discussions to develop appropriate action plans. •Investigates and coordinates the clinical review of files to analyze complaints. •Notifies the Provider and/or Facility Administrator of the results of the evaluation through written communication in compliance with the Policy and Procedure and requests action plans if necessary. •Participates in the meetings of the members of the Clinical Quality Management Peer Review Committee, to present the cases with trends and attends scheduled Quality Department meetings as required. •Discusses complaints and corrective action plans with providers and conducts follow-up to ensure implementation of corrective actions for complaints determined to have quality findings and/or trends related to quality of care. •Execute the evaluation and follow-up of Corrective Action Plans (CAPs) related to identified HACs, ensuring timely implementation, effectiveness validation, and compliance with quarterly ASES reporting requirements; conduct onsite and virtual meetings with hospital quality staff, including presentations of findings and action plans to support compliance and continuous improvement. •Prepare reports as requested by the management related to complaints/grievances received, determined, and action plans. ADDITIONAL FUNCTIONS: • Complies fully and consistently with Company standards, policies, and procedures, in conjunction with local and federal laws applicable to our Industry, business, and employment practice. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor of Science in Nursing. At least two (2) years of clinical experience performing tasks in a similar position. Certifications / Licenses: A valid License and Registration of Nurse & Association Nursing Professionals of Puerto Rico are required. Other: Knowledge of Industry Quality of Care requirements and regulations. Excellent English Oral and Written proficiency. Languages: Spanish – Advanced (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal)