Compliance Coordinator RN

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4 days ago Requisition

Salary Range: $48.67 To $77.92 Hourly

The Compliance Coordinator has oversight over regulatory compliance, quality and infection control related activities, safety and emergency preparedness and clinical education. This role ensures compliance with federal, state, CMS, and accreditation standards while promoting patient safety, quality outcomes, and preparedness for emergencies. The position collaborates with clinical leadership, administrators, and regulatory agencies to support continuous performance improvement and organizational readiness.

Does not oversee other staff

• Lead mock surveys and center assessments, prepare responses and corrective action plans as necessary
• Oversees organizational compliance with federal, state, local, CMS, and accreditation standards.
• Conducts audits, monitoring, and risk assessments to maintain regulatory readiness.
• Develops, reviews, and maintains policies and procedures supporting compliance.
• Coordinates accreditation surveys and serves as liaison with regulatory agencies.
• Monitor changes in state and federal law, assessing impact on ASC operations, and communicate changes to leadership.
• Provides compliance education and maintains required documentation.
• Ensures with CMS, CDC, OSHA, state, local and accreditation requirements.

• Facilitate and manage the onboarding process for new clinical employees, ensuring completion of all orientation pathways and skills checklists within required timelines.
• Develop, update, and implement annual high-risk clinical competencies for all staff to ensure compliance with regulatory standards (e.g., AAAHC, CMS, The Joint Commission).
• Provide or organize in-service education on new technology, equipment, and surgical techniques. Partners with clinical leadership to ensure annual education plans and staff competencies align with regulatory requirements and are completed on time.
• Organize and coordinate clinical in-services and regulatory drills, including annual Code Blue, Malignant Hyperthermia, and fire safety drills.
• Analyze educational outcomes and audit patient care to identify areas for improvement. Work closely with the Quality Management team to address deficiencies.
• Assist in creating, reviewing, and updating perioperative policies and procedures to reflect current evidence-based practices.
• Act as the primary liaison between clinical leadership, medical staff, and external trainers/vendors.
• Monitors, tracks, and assists with organizing in-services and staff education.
• Provides education, consultation, and committee coordination related to infection prevention.
• Provides education, consultation, and committee coordination related to safety and emergency preparedness.

• In coordination with the Quality Coordinator, supports the Center’s on-site quality management and performance improvement activities.
• Coordinates quality-related data collection, analysis, reporting, and committee functions.
• Supports quality reporting requirements, including ASC Quality Reporting measures.
• Identifies trends and recommends improvements to enhance patient safety and outcomes.
• Assists with and maintains the Infection Prevention and Control program, including surveillance and reporting.
• Participates with infection risk assessments and investigation with identified infections.
• Completes required public health reporting and documentation.
• Develops and maintains emergency management and safety programs.
• Develop and maintain all-hazards plans, policies and procedures.
• Conducts hazard vulnerability assessments, drills, and training.
• Identify potential threats and ensure resources are in place.
• Work with local law enforcement, emergency management agencies and public health officials as needed.
• Know the organization’s alert and notification system and procedures, and ensure appropriate staff is educated on this…