Hi, I’m
Victor R. Rosa
Clinical Quality Director
Coconut Creek,FL
Try again. Fail again. Fail better.
Samuel Beckett
Summary
Healthcare quality leader with 16+ years of experience leading performance improvement, regulatory compliance, and data strategy initiatives across Radiology and Emergency Medicine. Proven success managing MIPS programs, QCDR submissions, peer learning, and vendor accountability at the national level. Skilled at turning healthcare data into actionable insights and aligning quality efforts with clinical operations. Bilingual in English and Spanish.
Overview
16
years of professional experience
9
Years in leadership roles (Manager and Director)
3
Service Lines Supported (Radiology, Emergency, and Trauma)
2
Nationally recognized certifications (CPHQ, SSGB)
Work History
Envision Physicians ServicesFort Lauderdale, United States
Director of Clinical Quality Management
11.2017 - Current
Job overview
- Lead clinical quality and regulatory strategy across Envision’s Radiology, Trauma, and Emergency Medicine service lines, supporting over 500 radiologists and thousands of emergency clinicians and trauma surgeons nationwide.
- Conducted a cost-benefit analysis that supported the transition from ACR to the internal PQR QCDR, reducing per-physician reporting costs by over $1,500 annually and preserving approximately $3.2M in operational costs over three years while maintaining full CMS compliance.
- Oversee end-to-end MIPS reporting strategy, including performance monitoring, improvement implementation, and exemption coordination, mitigating $800K–$1.2M in annual risk through proactive compliance management.
- Direct regulatory preparedness and accreditation efforts, including Joint Commission accreditation for teleradiology, ACR and MQSA compliance, and USNRC oversight when needed. Maintain readiness for evolving federal programs such as PAMA across multiple imaging modalities.
- Serve as SME in collaboration with IT and project managers to enhance internal and external quality data platforms and reporting systems.
- Chair internal Clinical Quality Committees (CQC) for Radiology, Trauma, and Emergency Medicine to identify gaps in care, promote documentation standards, and deliver education and policy-based solutions.
- Lead implementation of an enterprise-wide quality framework, incorporating peer learning, QA reviews, and issue resolution processes across practices.
- Spearheaded lean process redesign for a major client system, contributing to the retention of 50% of the Florida book of business.
- Drove national turnaround time improvements through Power Metrics, consistently outperforming the 30-minute industry benchmark.
Envision Physicians ServicesPlantation, FL
Manager of Clinical Quality Management
05.2016 - 11.2017
Job overview
- Managed a team of 10 in achieving performance goals across 12+ clinical quality and compliance KPIs, including MIPS reporting, documentation standards, and peer review benchmarks.
- Partnered with clinical and operational stakeholders to address and mitigate quality-of-care concerns in a timely manner, improving resolution workflows and client satisfaction.
- Established and implemented quality control standards, processes, and documentation review protocols to meet organizational, regulatory, and accreditation requirements.
- Led quality assurance efforts, ensuring root cause analysis and issue resolution were completed within 24–48 hours of identification.
- Delivered educational sessions and quarterly performance updates to C-suite, clinicians, and department leaders, translating data insights into actionable quality improvements.
Sheridan HealthcorpSunrise, FL
Coordinator of Clinical Quality Management
05.2014 - 05.2016
Job overview
- Supported radiology accreditation compliance by managing submissions and documentation for ACR, MQSA, and other regulatory bodies, ensuring continuous proficiency and adherence to evolving standards.
- Resolved client-facing quality issues within 10–20 hours on average, significantly increasing customer satisfaction and improving retention with high-touch service.
- Developed and presented A3 problem-solving initiatives to senior leadership and cross-functional stakeholders to drive measurable improvements in clinical operations.
Sheridan HealthcorpSunrise, FL
Coordinator of Operations
07.2013 - 05.2014
Job overview
- Oversaw operations across five imaging centers, managing physician scheduling, addressing patient and provider complaints, and ensuring adherence to accreditation standards.
- Conducted onsite visits to monitor quality performance, enforce clinical standards, and support regulatory readiness.
- Provided teleradiology operational support, resolving urgent issues and facilitating communication across remote teams.
- Collaborated with practice management leaders to execute high-priority initiatives, prepare client-facing presentations, and implement action plans.
- Implemented workflow improvements and new technologies, reducing dictation turnaround time by 85%.
- Identified and resolved unauthorized or unsafe operational practices, improving safety and compliance metrics.
Sheridan HealthcorpSunrise, FL
Liaison of Operations
08.2012 - 07.2013
Job overview
- Managed a high-volume call center, ensuring responsive service and coordination of critical communications between medical professionals and facilities.
- Facilitated timely relay of critical radiology findings to improve care transitions and diagnostic accuracy.
- Conducted 50% critical results audits to ensure compliance with communication protocols and improve patient safety.
- Evaluated operational workflows against established checklists, identifying and escalating gaps in quality or handoff processes.
- Streamlined operations by implementing efficient workflow processes and procedures.
- Developed strong relationships with clients, resulting in favorable terms with operations and quality improvement.
Sheridan HealthcorpLauderdale Lakes, FL
Liaison of Facility Operations
04.2009 - 08.2012
Job overview
- Managed reading room and outpatient procedure workflows, including scheduling coordination across departments.
- Led a Kaizen-based process improvement initiative to reduce turnaround times and improve stroke patient throughput between Emergency and Radiology departments.
- Supported radiology call center functions, addressing 100% of clinician and patient inquiries with timely follow-up and resolution.
- Applied newly acquired process improvement and clinical operations knowledge to daily tasks, enhancing efficiency and team productivity.
North Broward Medical Center – (Internship) Deerfield Beach, FL
Quality, Safety & Emergency Preparedness
08.2011 - 12.2011
Job overview
- Conducted mock tracers across 40% of hospital units to assess Joint Commission (TJC) accreditation readiness, reporting findings to the Director and VP of Emergency Preparedness & Quality.
- Analyzed needlesticks injury data to support policy revisions and quality improvement efforts targeting occupational safety.
- Observed C-suite “go/no-go” decision-making on Pyxis pharmasuticl maticine / technology implementation, evaluating impacts on nursing workflow and patient outcomes.
- Completed health administration preceptorship as part of undergraduate program requirements, contributing to hospital-wide safety and quality initiatives.
Education
Florida Atlantic UniversityBoca Raton, FL
Master of Science from Health Administration-Management
05.2016
Florida Atlantic UniversityBoca Raton, FL
Bachelor of Science from Healthcare And Business Administration
12.2011
Broward CollegeFort Lauderdale, FL
Associate of Arts from Health Administration
05.2009
Sheridan Technical CollegeHollywood, FL
Associate of Science from Automotive Technology
08.2006
Skills
- Clinical Quality Strategy & Improvement
- Regulatory Compliance (CMS, Joint Commission, ACR, MQSA, USNRC)
- MIPS Reporting & QCDR Management
- Performance Improvement & Data Analytics
- Peer Learning & Quality Assurance Program Design
- Cross-Functional Leadership & Stakeholder Collaboration
- Change Management & Process Redesign
- Physician & Clinician Engagement
- Training & Development (Clinician and Staff Education)
- Vendor & RCM Partnership Management
- Accreditation Readiness (Teleradiology, Ambulatory, Nuclear Medicine)
- Risk Mitigation & Root Cause Analysis
- Healthcare IT Systems & Quality Data Platforms
- Policy Reinforcement & Clinical Standards Alignment
- Lean / Continuous Improvement Methodologies
- Bilingual: English / Spanish
Certification
Certified Professional in Healthcare Quality - CPHQ
Six Sigma Green Belt Certification - SSGBC
Affiliations
- Member, National Association for Healthcare Quality (NAHQ)
- Member, Institute for Healthcare Improvement (IHI)
- Member, American College of Healthcare Executives (ACHE)
- Envision Healthcare Champion, JDRF Fundraising Efforts (2003–2007)
- Envision Healthcare Member, Unity Battalion Employee Resource Group (Military & Veteran Support)
- Envision Healthcare Advocate, Mental Health Employee Resource Group (ERG)
Availability
See my work availability
Not Available
Available
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
swipe to browse
Accomplishments
- Reduced operational costs by $3.2M over three years by leading the transition from ACR to an internal CMS-approved QCDR, streamlining regulatory reporting across 500+ radiologists.
- Directed MIPS quality reporting strategy, mitigating $800K–$1.2M in annual risk through proactive monitoring, exemption coordination, and performance improvement initiatives.
- Led the design and execution of randomized peer review processes, reviewing over 850,000 cases annually to improve diagnostic accuracy across the enterprise.
- Led the transformation from traditional score-based peer review to an ACR-endorsed peer learning program, fostering a non-punitive, educational culture that enhanced radiologist engagement and improved diagnostic accuracy across the enterprise.
- Provided strategic leadership in preparing the enterprise for CMS PAMA (Protecting Access to Medicare Act) requirements, conducting cross-functional readiness assessments, aligning workflows, and ensuring the organization was positioned for future compliance despite federal program delays.
Timeline
Director of Clinical Quality Management
Envision Physicians Services
11.2017 - Current
Manager of Clinical Quality Management
Envision Physicians Services
05.2016 - 11.2017
Coordinator of Clinical Quality Management
Sheridan Healthcorp
05.2014 - 05.2016
Coordinator of Operations
Sheridan Healthcorp
07.2013 - 05.2014
Liaison of Operations
Sheridan Healthcorp
08.2012 - 07.2013
Quality, Safety & Emergency Preparedness
North Broward Medical Center – (Internship)
08.2011 - 12.2011
Liaison of Facility Operations
Sheridan Healthcorp
04.2009 - 08.2012
Florida Atlantic University
Master of Science from Health Administration-Management
Florida Atlantic University
Bachelor of Science from Healthcare And Business Administration
Broward College
Associate of Arts from Health Administration
Sheridan Technical College
Associate of Science from Automotive Technology
Similar Profiles
Lennis BejaranoLennis Bejarano
Anesthesia at Envision Physicians ServicesAnesthesia at Envision Physicians Services
Saranny GrangerSaranny Granger
Patient Services Supervisor at Envision Physicians ServicesPatient Services Supervisor at Envision Physicians Services
Jennifer GutierrezJennifer Gutierrez
Emergency Advance Practice Registered Nurse at Envision Physicians ServicesEmergency Advance Practice Registered Nurse at Envision Physicians Services
Eduardo VitierEduardo Vitier
Lead Maintenance Technician at Northland InvestmentsLead Maintenance Technician at Northland Investments
Kristen GarciaKristen Garcia
Project Manager Patient Experience at Mass General BrighamProject Manager Patient Experience at Mass General Brigham