Quality Clinical Review Specialist - Performance Improvement

A Quality Clinical Review Specialist plays a vital role in the healthcare industry by assessing the medical necessity and appropriateness of healthcare services provided to patients. Their primary responsibility is to review medical records and treatment plans to ensure that they align with established guidelines and standards. The reviews will be targeted to specific patient populations (as directed by primary diagnosis, complication occurrence, etc.) whose care we are looking to impact.


Essential Functions:

• Daily review of established quality indicators work queue.
• Creating necessary queries to intervene on the chart and identify the provider. Supporting or leading work around quality and improvements.
• Present to wide audiences on topics related to quality patient safety measures and opportunities.
• Reviews and applies analytical skills to designated patient population medical record documentation to assess the level of documentation accuracy and completeness.
• Collaborate with coding department to revise final coding. Data management for clinical databases and/or registries, including validation of appropriate patient list submission to abstractors, validate abstractor data is accurate and complete, and ensure data submissions are complete for any harvest or submission deadlines.
• Operate as a subject matter expert for assigned clinical databases/registries to assist Performance Improvement Specialists and Service Line leaders in any registry-involved projects.

• Bachelor's Degree in Nursing.
• Registered Nurse in the State of Florida.
• Minimum of 3 years experience.
• ACDIS Clinical Documentation Improvement (CDI) apprenticeship, including basic clinical coding knowledge. If not already completed, training required to be completed within first 3 months of employment.
• An equivalent combination of education/certification and realized competencies

• Strong knowledge of medical terminology, disease processes, and treatment modalities.
• Proficiency with reading and applying data sets from specific platforms used in the organization.
• Provide clear and concise written and verbal communication. Basic understanding of writing physician queries.
• Ability to navigate complex clinical processes and be effective with physicians, nurses, and other care providers.
• Attention to detail and ability to prioritize tasks in a fast-paced environment.
• Knowledge of the ICD-10 diagnosis and procedure codes Basic understanding of writing physician queries.
• Knowledge of AHRQ PSI Technical Specifications.
• Knowledge of CMS hospital acquired conditions.
• Strong proficiency with excel and data analysis tools.
• Experience with chart reviews in electronic medical records, clinical data, supporting or leading work around quality and improvements and creating and/or presenting education material.
• Experience with clinical registries and database either in data management or abstraction. Understanding inclusion/exclusion criteria, identifying improvement opportunities and resolving data or documentation errors or omissions.
• Experience in working with interdisciplinary teams including coding, CDI, senior leadership, performance Improvement, and physicians with confidence and transparency.