Compliance and Quality Coordinator, Healthyhorns

Regulatory and Policy Compliance Executes day-to-day compliance and risk monitoring activities across clinical and administrative workflows, including spot checks and targeted reviews to verify adherence to policies and procedures.Updates policy and procedure based on the guidance and instruction of stakeholders; tracks the progress of policies in workflow and provides support to assure timely review and approval in collaboration with the Healthyhorns Policy and Procedure Coordinator.Collects and analyzes compliance data; ensures documentation meets regulatory, policy, and accreditation standards.In collaboration with the Healthyhorns Clinical Staff Educator/Infection Prevention and Safety Coordinator, support documentation of staff training and compliance, including tracking completion and maintaining training records.Tracks patient complaints and compliance gaps; documents findings, escalates issues per protocol, identifies areas for opportunity and supports corrective actions.Quality ImprovementAssists with management and coordination of quality improvement (QI) studies and projects from planning through sustainment.Writes study reports and synthesizes finds for stakeholders.Leads gap analysis exercises to identify root causes and prioritize improvement opportunities.Track corrective action plans, follow up with owners on timelines and deliverables.Coordinates remeasurement cycles to assess post-corrective action implementation performance and sustainment.Monitors and tracks communication to staff on QI studies and other educational activities.Assists data collection, performance measurement, and reporting for clinical quality, safety, and patient experience indicators.Supports peer review activities and generate summary reports that synthesize trends, recommendations, and follow-up actions.Assists in preparing for AAAHC accreditation and survey readiness.Serves as a resource for continuous quality improvement frameworks, best practices and tools.Other Project Management Functions Plans, develops, implements, and evaluates other projects as assigned by Assistant Director for Quality Management in coordination with other administrators and staff in Healthyhorns.Partners with the Clinical Staff Educator/Infection Prevention and Safety Coordinator to advance risk management and compliance through a team-based, collaborative approach.Exhibits behaviors consistent with the items listed below:Uses the Customer Service Standards as the benchmark for all interactions with patients and other customers.Treats others with dignity and respect, regardless of individual differences.Knows, understands and abides by:Healthyhorns Patient Rights and Responsibilities statementHealthyhorns Principles of Professional ConductHealthyhorns and department-specific Policies and ProceduresRespects patient privacy and maintains confidentiality, disclosing protected health information only as it relates to the plan of care for that patient.Supports and participates in quality improvement efforts, including adjusting performance and practice in accordance with quality improvement initiatives and findings.