Quality and Compliance Coordinator

Position type: Full-Time

Pay/Salary: $40,560- 55,120

Pay: Annual Salary: $40,560 – $55,120

Schedule: Monday – Friday, 8:00 AM – 5:00 PM

Departments Supported: Quality Management, Risk Management, Patient Safety

At Sarah

D. Culbertson Memorial Hospital, we believe that quality healthcare starts with compassion, collaboration, and community. As a Critical Access Hospital serving Rushville and surrounding areas, our mission is to provide accessible, high quality care close to home.

We are looking for a candidate who wants to become a long‑term member of our team as a Quality and Compliance Coordinator. This role offers the opportunity to grow within a supportive, mission‑driven environment where your work directly impacts patient safety, regulatory excellence, and operational integrity. The ideal candidate is organized, detail‑focused, and passionate about building strong systems that support high‑quality care and compliance across the organization.

The Quality and Compliance Coordinator serves as the hospital's central resource for policy management, contract administration, regulatory compliance, accreditation readiness, and quality documentation. This position supports organizational compliance with CMS Conditions of Participation, Critical Access Hospital regulations, state and federal requirements, accreditation standards, and governing board expectations.

The coordinator maintains oversight of the hospital's policy management process, contract management system, regulatory tracking activities, and quality documentation systems while supporting continuous survey readiness and organizational performance improvement initiatives.

• Maintain the hospital’s master inventory of policies, procedures, forms, and protocols
• Coordinate annual and periodic policy reviews with department leaders and policy owners
• Track policy deadlines and follow up on overdue reviews
• Ensure policies are reviewed, approved, revised, and archived according to standards
• Manage policy version control and document retention processes
• Maintain electronic policy management systems and document repositories
• Generate compliance reports for leadership and governing board committees
• Support departments with policy development, formatting, and approval workflows

• Track contract effective dates, renewals, expiration dates, and notice periods
• Coordinate contract review workflows with leadership, legal, and governing board
• Maintain executed contract files and supporting documentation
• Monitor contract compliance requirements and reporting obligations
• Provide monthly contract status reports to executive leadership
• Assist departments with vendor agreements and service contract tracking
• Ensure contracts meet organizational retention requirements

• Monitor and interpret regulatory and accreditation requirements impacting hospital operations
• Support compliance with CMS Conditions of Participation, CAH regulations, IDPH, OSHA, and other standards
• Coordinate documentation for surveys, audits, and accreditation reviews
• Maintain compliance files and evidence repositories
• Track and monitor corrective action plans from surveys and reviews
• Support ongoing survey readiness and compliance initiatives

• Assist with quality improvement and patient safety initiatives
• Maintain quality committee records, including meeting minutes and documentation
• Support collection and reporting of performance indicators
• Track performance improvement projects and outcomes
• Maintain dashboards and quality reporting tools
• Assist with root cause analysis documentation and follow‑up
• Prepare reports for leadership, medical staff, and governing board

• Prepare reports and materials for Quality, Compliance, Medical Staff, and Governing Board meetings
• Assist in maintaining bylaws, committee charters, and governance documents
• Support board reporting requirements and administrative processes
• Maintain confidentiality of sensitive and privileged information
• Perform additional duties as assigned