Clinical Practice and Policy Specialist (RN)

Under the direction of the Manager of Clinical Policy & Standards and in collaboration with Clinical Excellence leadership, the Clinical Practice and Policy Specialist serves as a clinical expert responsible for advancing nursing practice, clinical policy, and care standardization across the organization.

This role combines system-wide policy coordination with frontline clinical practice support to ensure that policies are developed, implemented, and sustained in alignment with organizational standards, regulatory requirements, and evidence-based practice. Working closely with nursing leadership, interdisciplinary teams, subject matter experts, and frontline caregivers, the Clinical Practice and Policy Specialist promotes safe, high-quality, and consistent patient care throughout the acute care environment.

Key Responsibilities

Clinical Policy Development & Implementation

• Lead the development, revision, implementation, and ongoing maintenance of clinical practice policies and standards.
• Coordinate policy review workflows, stakeholder feedback, approvals, and documentation within the organization's policy management system.
• Ensure policies remain current, evidence-based, operationally relevant, and aligned with organizational goals.
• Translate system-wide policies into practical unit-level workflows and support successful implementation across clinical departments.

Leadership Collaboration & Stakeholder Engagement

• Partner with nursing leaders, operational leaders, physicians, subject matter experts, and interdisciplinary teams to support policy development and adoption.
• Serve as a liaison between system leadership and hospital-based teams to promote consistent interpretation and application of clinical policies.
• Engage frontline staff to gather feedback, identify practice gaps, and support continuous improvement initiatives.

Regulatory Compliance & Survey Readiness

• Support organizational compliance with Joint Commission, CMS, state, and other regulatory requirements.
• Participate in survey readiness activities, mock surveys, tracers, audits, and documentation reviews.
• Assist leaders with corrective action planning, regulatory responses, and ongoing compliance monitoring.
• Promote sustained readiness through education, coaching, and performance improvement initiatives.

Clinical Practice Standardization

• Promote consistent, evidence-based clinical practice across departments.
• Identify variation in care delivery and recommend opportunities for standardization.
• Reinforce policies and best practices that improve patient safety, quality, and clinical outcomes.
• Collaborate with Clinical Excellence and Nursing Professional Development teams to align organizational standards and practice expectations.

Evidence-Based Practice & Quality Improvement

• Translate current research and evidence into clinical practice improvements and policy enhancements.
• Support implementation of evidence-based interventions that improve patient outcomes and nursing practice.
• Partner with clinical teams to evaluate nursing-sensitive indicators and other quality performance measures.
• Share best practices through education, presentations, mentoring, and consultation.

Data Analysis & Outcomes Management

• Analyze clinical quality, safety, and operational data to identify trends and opportunities for improvement.
• Collaborate with nursing and operational leaders to develop, monitor, and evaluate performance metrics.
• Provide data-driven recommendations that support clinical excellence and informed decision-making.

Clinical Rounding & Practice Support

• Conduct structured clinical rounds to assess adherence to policies, standards, and evidence-based practices.
• Provide real-time coaching, consultation, and support to frontline clinical staff.
• Identify barriers to practice and collaborate with leaders to implement sustainable solutions that improve patient care.

Qualifications

Required

• Current, unrestricted Registered Nurse (RN) license.
• Masters's degree in Nursing (MSN).
• Minimum of three to five years of progressive clinical nursing experience.
• Experience in clinical policy development, evidence-based practice, quality improvement, or nursing leadership.
• Strong knowledge of healthcare regulations, accreditation standards, and nursing professional practice.
• Excellent communication, collaboration, project management, and analytical skills.

Benefits:

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