Quality & Compliance Coordinator

Job Description

Job Description

Overview

This role supports the Quality & Compliance team and coordinates cross-functionally by performing administrative, regulatory, and project-based activities across the department and the ASCs, while contributing to quality, and compliance initiatives.

The coordinator serves as a key point of coordination for ASC regulatory readiness, policy and contract

administration, document control, and continuous improvement, working closely with quality, compliance, and legal leadership and maintaining a high degree of confidentiality.

Responsibilities

• Provides administrative and coordination support to the Quality & Compliance department maintaining a high

degree of confidentiality

• Assists with the preparation and creation of quarterly QAPI reports

• Assists with Peer Review assignment distribution, tracking, and creating reports

• Processes incident reports for insurance claims and coordinates related follow-up activities

• Maintains QAPI training completion records and performs follow-up as needed

• Coordinates quarterly THCIC reporting for Texas ASCs, ensuring accurate data submission, timely filing, and

compliance with all Texas Health Care Information Collection (THCIC) requirements

• Assists Sr. Director of Quality with the Merit-based Incentive Payment System (MIPS) performance monitoring,

data validation, provider updates and staff follow-up

• Tracks meeting dates and updates applicable reports and documents accordingly

• Assists with report creation and data entry within the Compliance Line (myMCM) platform

• Processes form translation requests for the department

• Assists with compliance monitoring activities as needed by the Compliance Manager

• Updates surgical forms changes including editing grammar, punctuation, or spelling as needed. This requires

knowledge of healthcare vocabulary and limited range of specialized terminology

• Assists with preparation for surveys (AAAHC, CMS), serves as the AAAHC database contact person and

maintains required documentation

• Following pre-determined format, reviews each ASC’s Medicare Survey Book to verify accuracy, completeness

and alignment with current CMS requirements, ensuring all documents, policies, and supporting evidence are

updated and ready for surveyor review

• Coordinates with the department leaders and the ASC Regulatory Specialist (or similar role) on necessary

updates to policies and procedures, maintaining version control, and ensuring all documents remain current

and properly archived; requires strong proficiency in the MedTrainer platform for policy updates, tracking, and

distribution

• Coordinates Infection Control training for the ASC Managers and Directors

• Provides support for CSOS (Controlled Substance Ordering System) by coordinating with the Procurement

department to ensure compliant and timely procurement of controlled substances

• Monitors all Unplanned Hospital Transfers to confirm required documentation is complete, accurate, and

submitted, ensuring timely follow-up and compliance with ASC reporting standards

• Ensures ASC regulatory filings are coordinated and completed timely cross-departmentally

• Performs other duties as assigned

Qualifications

Education:

• High school diploma or equivalent

• Associate’s degree or equivalent experience preferred; coursework or experience in healthcare administration,

compliance, ASC regulations and survey requirements, or a related field is a plus

Experience:

• Good knowledge of basic legal and regulatory requirements and procedures in the healthcare setting

• Demonstrates ability to support compliance functions, including handling confidential and privileged

information with discretion

• Strong organizational and project-coordination skills, with the ability to manage multiple priorities, deadlines,

and stakeholders independently

• Familiarity with contract administration, policy management, and document/version control systems (e.g.,

MedTrainer)

• Excellent oral and written communication skills

• Excellent clerical and administrative skills

• Ability to present a professional image of the department to consumers, the public, staff and Board at all times

• Highly self-motivated, flexible, and direct, with the ability to work cooperatively with others as a

productive team member

• Excellent communication skills, written and verbal, with a high standard of positive interaction with all team

members, clinic employees, clients, and members of the community

• Ability to support a work team by demonstrating a positive attitude, openness to change, willingness to help

cross-departmentally, and respect for others and their ideas

• Ability to maintain a positive, solution-focused demeanor when responding to conflicts or problems

• General computer proficiency, including accurate typing and proficiency in the Microsoft Office Suite