Quality & Compliance Coordinator (3709)

Position Summary:

The Quality and Clinical Compliance Coordinator supports the Director of Nursing in maintaining regulatory compliance, promoting quality improvement initiatives, and ensuring adherence to federal, state, and organizational standards across resident care services. This role focuses on quality assurance activities, survey readiness, clinical documentation review, infection prevention support, policy management, and performance improvement initiatives. The position works collaboratively with nursing staff, providers, and interdisciplinary team members to promote resident safety, positive outcomes, and continuous quality improvement. While limited supervisory responsibilities may be assigned, the primary focus of this position is quality monitoring, regulatory compliance, staff education, and process improvement.

Key Responsibilities:

• Coordinate and support the facilitys Quality Assurance and Performance Improvement (QAPI) program.
• Conduct routine clinical record audits to evaluate compliance with federal and state regulations, facility policies, and documentation standards.
• Monitor quality indicators, resident outcomes, infection surveillance data, incident reports, and performance metrics.
• Assist with preparation for state, federal, and accreditation surveys, including ongoing survey readiness activities.
• Participate in development, implementation, review, and revision of clinical policies, procedures, and quality improvement plans.
• Identify opportunities for performance improvement and assist in implementing corrective action plans.
• Monitor compliance with infection prevention practices, resident safety initiatives, and quality measures.
• Assist with investigation and follow-up of incidents, grievances, concerns, and quality-related events.
• Support staff education initiatives related to regulatory requirements, quality measures, documentation standards, and best practices.
• Assist with monitoring completion of assessments, care plans, physician orders, and required clinical documentation.
• Compile and analyze quality data and prepare reports for leadership, committees, and governing bodies.
• Participate in interdisciplinary meetings focused on resident outcomes, quality initiatives, and regulatory compliance.
• Provide limited clinical support and oversight as delegated by the Director of Nursing.

Licenses and Certifications Required:

• Current North Dakota RN or LPN license in good standing. BLS certification.

Educational Requirements:

• Graduate of an accredited nursing program.

Experience Requirements:

• Long-term care, swing bed, skilled nursing, or rural healthcare experience.
• Quality assurance, regulatory compliance, infection prevention, risk management, or survey preparation experience preferred.
• Experience conducting audits, reviewing clinical documentation, and monitoring quality indicators preferred.

Special Skills or Training Requirements:

• Knowledge of CMS regulations, state survey processes, and long-term care requirements.
• Strong organizational and analytical skills.
• Ability to interpret regulations and apply them to clinical practice.
• Effective written and verbal communication skills.
• Proficiency with electronic health records, spreadsheets, and data tracking systems. Ability to work independently while collaborating with interdisciplinary teams.

Physical Requirements:

Ability to move throughout resident care areas, perform clinical observations, review documentation, and participate in quality monitoring activities. Occasional resident care assistance may be required.

Environmental Requirements:

This position works primarily in an office and healthcare environment with routine exposure to computers, standard office equipment, and multiple clinical or operational departments. The role may involve periodic exposure to patient care areas where contact with infectious illnesses, healthcare-related hazards, or cleaning agents may occur. Adherence to organizational safety procedures, confidentiality requirements, infection prevention practices, and applicable regulatory standards is required at all times.