Clinical Quality Compliance Consultant Wilkes Medical Center

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Wake Forest Baptist Health
May 13, 2021
Wake Forest, North Carolina
Job Type


Job Description
Job Title:
Clinical Quality Compliance Consultant Wilkes Medical Center
Job ID:
Full/Part Time:
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Major Duties

JOB SUMMARY:  Under supervision, works to strengthen Wake Forest Baptist Health’s system-wide quality outcomes reporting and improvement activities.  Works with leadership to comply with an increasing number of external reporting mandates and improvement initiatives including data collection, data entry, and analysis of quality data.  In addition, responsible for data display and interpretation, and the reporting of this data to a wide range of clinical and administrative leaders.   Extensive, daily interaction with leaders and staff in the Quality and Safety division is a key component of this role.  Participates in a variety of programs and improvement activities across multiple academic and operational departments.


EDUCATION/EXPERIENCE:  Graduation from an accredited School of Nursing and a bachelor’s degree in a related health or business field required; or, ten years of clinical experience and three years of related healthcare quality experience required. Master’s degree preferred.  Five to seven years of experience in quality measurement/improvement, healthcare data analysis, patient safety, or health science research, and knowledge of regulatory agency standards and requirements strongly preferred.  Experience working in a complex healthcare system preferred.


LICENSURE, CERTIFICATION, and/or REGISTRATION:  Current license to practice as a Registered Nurse (RN) in the State of North Carolina required.  Certification as a Certified Professional in Healthcare Quality (CPHQ) required within three years of employment.



  1. Facilitates compliance with evolving quality measures and reporting requirements, including CMS Quality Reporting Programs, TJC Oryx Reporting, Leapfrog, National Quality Forum quality measures, and other benchmarking or public quality reporting programs.
  2. Oversees clinical review in areas of responsibility to ensure complete and accurate data collection and data entry for assigned performance measures and projects within established timeframes.  Facilitates internal and external data validation processes.
  3. Develops both measurement and improvement strategies for assigned performance measures and projects and assists with benchmarking performance and setting goals for improvement.
  4. Demonstrates operational knowledge and ability to work within a variety of health information systems, databases, and software applications or platforms, including government and regulatory agency web-based systems.
  5. Works with department leadership to investigate quality concerns or issues arising from external payer reviews, public quality reporting and clinical benchmarking efforts (e.g. Hospital Compare, NSQIP, Vizient, Leapfrog, TJC, etc.), or surveillance of major outcome measures (e.g. mortality, readmission, reoperation rates, etc.).
  6. Provides concise clinical quality review findings, develops recommendations for corrective actions and/or improvement opportunities to leadership as warranted, and monitors the impact of implemented changes.
  7. Works with designated teams and quality leaders across the medical center to strengthen clinical documentation and coding to ensure that patient complexity and clinical course are accurately reflected.  Monitors review processes for hospital acquired conditions and publicly reported quality and safety indicators to ensure that accurate information is reported to regulatory agencies.
  8. Collaborates with department leaders to manage designated quality and safety related projects and assignments.
  9. Establishes and maintains effective and collaborative working relationships with members of the hospital community, clinical departments, administrative departments, and quality and safety staff across Wake Forest Baptist Health.
  10. Assumes responsibility for self-directed continuing education and professional development and demonstrates applied learning.  Contributes to staff education in assigned areas.
  11. Performs other duties as assigned.



Superior organizational and interpersonal skills with ability to work independently

Knowledge of state and federal regulations specific to external reporting mandates

Excellent communication and follow up accompanied by the ability to analyze and present data in a way to influence and change behavior

Excellent creativity and enthusiasm for developing and implementing new programs

High degree of professionalism, discretion, and confidentiality

Comfortable interacting with a vast array of administrative and clinical staff, ranging from the Chief Medical Officer and department Chairs, to frontline care providers

Experience with performance improvement methods, including statistical concepts and applications

Strong project management skills with experience in planning, facilitating, and organizing teams

Strong computer skills (Word, Excel, and PowerPoint applications), preferably 2010 version

Ability to be flexible accommodating clinicians schedules when early or late meetings are necessary



How to Apply

To apply for this position, please click on the "Apply Now" button on this page.  You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".

Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina  27104. You may also call our office for assistance at (336) 716-6464.  Office hours are Monday-Friday, 8:00am-5:00pm.

If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at

Equal Employment Opportunity

It is the policy of  Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation, gender identity or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.

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