Job Description

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.

Key Responsibilities

Clinical Peer Review Coordination

• 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.

Medical Staff & Committee Support

• 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.

Healthcare Quality & Regulatory Compliance

• 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.

Data Analysis & Reporting

• 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.

Collaboration & Communication

• 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.

Additional Responsibilities

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

Qualifications

Education

• Bachelor's degree in nursing, Healthcare Administration, Health Information Management, or a related healthcare field required.
• Bachelor of Science in Nursing (BSN) required.
• Active Registered Nurse (RN) license preferred.

Experience

• 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.

Required Knowledge & Skills

• 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

Preferred Certifications

• Certified Professional Medical Services Management (CPMSM)
• Certified Professional in Healthcare Quality (CPHQ)

• 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