Clinical Quality Senior Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 65,000 - 90,000; Full time

Job summary

MCS Puerto Rico seeks a knowledgeable Quality Improvement professional to support the Quality Improvement Program and ensure timely CMS submissions. The role ensures compliance with regulatory requirements, oversees HAC/NE processes, and coordinates grievances with cross‑functional teams.

The candidate will develop and monitor quality initiatives, prepare reports, and support audits while guiding efforts across departments to maintain high standards of care.

Qualifications

• Bachelor of Science in Nursing and a clinical background in quality of care required.
• Minimum three years of experience in clinical areas, medical records review, or quality of care.
• A valid Puerto Rico nursing license and registration are required.
• Bilingual proficiency: Spanish and English at advanced level.

Responsibilities

• Serve as liaison and SME on quality standards and regulatory requirements.
• Prepare clinical sections of annual QI Program Evaluation and CMS submissions.
• Oversee HAC and Never Events reporting in compliance with regulations.
• Coordinate quality-of-care grievances and ensure timely regulatory deadlines.
• Lead quality initiatives, develop work plans, and track progress.
• Analyze outcomes and present findings to leadership for decisions.

Skills

Quality improvement

Regulatory compliance

Project coordination

Data analysis

Stakeholder engagement

Education

Bachelor of Science in Nursing

Job description

GENERAL DESCRIPTION

Provides cross-functional collaboration to support the Quality Improvement Program, ensuring timely submissions, adherence to established timelines, and successful execution of quality initiatives. Responsible for the Quality of Care (QOC) process, leads task forces, and serves as the subject matter expert on quality standards, regulatory requirements, and performance improvement activities.

Regular Exempt

ESSENTIAL FUNCTIONS

• Serves as a liaison and subject matter expert on quality standards, regulatory requirements, quality improvement methodologies, providing guidance and training to promote best practices, support compliance, and ensure adherence to applicable federal, state, and organizational requirements.
• Responsible for preparing clinical sections of the annual QI Program Evaluation, QI Description and documentation of written reports of the Quality Improvement Projects (CCIP and QIP) for CMS submission.
• Responsible for the Hospital Acquired Conditions (HAC) and Never Events (NE) process and timely report submission in compliance with regulatory requirements.
• Executes and evaluates the process related to the evaluation of all Quality-of-Care grievances referred by the Unit of Grievances and Appeals promptly, assuring compliance with regulatory deadlines, maintenance of quality management records, and tracking, trending, and analysis of quality.
• Ensures proper resolution of complex/severe Quality of Care (QOC) grievances and/or determination appeals received from the evaluated provider, which require the intervention and evaluation of the Clinical Review Committee and/or third-party evaluation (Advance Medical Review) for final determination.
• Conducts clinical quality initiatives or project coordination as assigned, including presentations, meetings, meeting minutes, interactions with other departments, providers, and external clients.
• Facilitates project taskforces using QI techniques to ensure effective project scope definition, identify activities needed to meet project objectives, work plan development and implementation of interventions, and data analysis (ex. Cardiovascular, Hypertension, Chronic Kidney Disease, indicators, among others).
• Develops and manages work plans for quality initiatives and projects, providing ongoing oversight, follow‑up, and progress tracking to ensure timely execution and completion of all assigned activities.
• Analyzes, documents and monitors quality project outcomes, trends, and key performance indicators, comparing results across similar initiatives to identify best practices and improvement opportunities. Prepares and presents project findings, barriers, risks, outcomes, and recommendations to leadership for review, decision‑making approval and to update the Quality Improvement Projects (QIC).
• Ensures to submit project documentation to Centers for Medicare & Medicaid Services (CMS) within the requested time and standard requirements.
• Revises and updates policies and procedures to reflect current internal processes related to assigned quality projects and presents them for approval.
• Provides support for internal and regulatory agency audits on quality-of-care issues.

ADDITIONAL FUNCTIONS

• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• 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 three (3) years of experience working in clinical areas, review of medical records, or areas related to quality of care.

Certifications / Licenses: A valid Nurse & Association Nursing Professionals of Puerto Rico License and Registration is required. Other: Knowledge of Industry Quality of Care requirements and regulations is preferred.

Languages: Spanish – Advanced (comprehensive, writing and verbal) English – Advanced (comprehensive, writing and verbal)

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