Quality Governance Coordinator

Main Hospital - Los Angeles, CA 90026 Overview Salary Range: $95,000.00 - $ Salary/year Description Title of Position:
Quality Governance Coordinator

Location:

Gateways Hospital & Mental Health Center Exempt/Non-Exempt:
Exempt Union/ Non-Union:
Non-Union Supervisor:
Director of Quality Improvement

The Quality Governance Coordinator is responsible for the comprehensive management and maintenance of Agency-wide documents. This includes ensuring that all documents are accurate, well-organized, kept up-to-date, easily accessible, and in compliance with all relevant requirements and Agency standards. Key responsibilities involve overseeing and tracking documents throughout their entire lifecycle. This process encompasses the creation, regular updates, approval, archiving, retirement, and replacement of outdated documents.

The scope of documents managed includes all Agency-wide policies and procedures, clinical documents and forms, as well as other relevant patient care documents such as protocols or workflows. The Quality Governance Coordinator maintains all documents within the Agency database, ensuring that each document is preserved in a functional manner, remains accurate, and is accessible to authorized staff members when needed.

Essential activities carried out in this role include receiving, reviewing, categorizing, scanning, filing, and tracking documents that are critical to the effective operation of the Quality Improvement Department and Clinical programs.

• Develop and maintain the central database for all policies and procedures, clinical documents, and forms for every department within the organization, ensuring all information is accurate and up to date.
• Provide training for database users on navigating the system, as well as accessing relevant policies, documents, and forms.
• Develop and oversee a document control policy that defines the procedures, lifecycle, and provides detailed descriptions of each section within the policy template.
• Oversee document lifecycle management, from creation to archival or retirement.
• Develop and update policies as needed, consulting subject matter experts to ensure alignment with department or program requirements and workflows.
• Communicate and coordinate with the committee chair to ensure timely submission of required documents in preparation for the committee meeting.
• Follow up with all contributors involved in creating or updating documents to ensure progress, and support further follow-up as needed. Determine when delaying approval is appropriate to ensure adequate review and feedback, while still meeting any pertinent requirements or deadlines.
• Update and create new templates as needed.
• Ensure that accurate information is entered into the database for each document as it progresses through the document lifecycle.
• Track all documents, including the name of the document, the document owner, status, and planned approval date and committee.
• Engage with department leadership and provide status reports on a routine basis regarding policies, documents, or forms currently under review.
• Coordinate and engage with Electronic Health Record System (EHRS) staff to keep form updates synced between the system and documentation.
• Maintain organization of clinical forms to ensure a smooth transition to Downtime Procedures for all EHRS users.
• Facilitate annual review of policies that have not been reviewed within 3 years of their latest approval date, ensuring all policies have been reviewed minimally every 3 years.
• Ensure that only the correct, approved versions of documents are in circulation.
• Verify that all documentation adheres to internal policies and external regulatory standards.
• Properly store, archive, retire, or dispose of documents, according to Agency policy.
• Maintain Word and PDF forms up to date, and provide a fillable PDF for staff, particularly for clinical use during downtime.
• Submit all required documents for legal, accreditation, regulatory, compliance, risk management, or leadership requests.
• Performs other additional tasks as directed.

• Minimum of 1 year of experience related to control of documents, such as policies and procedures or clinical forms.
• Minimum of 2 years of experience related to drafting and revising Agency documents, in alignment with regulatory, contractual, or accreditation requirements.
• Familiarity with regulatory bodies and standards (e.g., HIPAA, CMS, Title, 42, Title 22)
• Demonstrated knowledge of Adobe Acrobat Pro or Nitro Pro, Microsoft Word, and Excel.

• Experience in compliance, quality improvement, or administrative coordination preferred.
• Document control software and EHR system experience preferred.

• Master’s degree.
• Active clinical licensure required

• Must pass Department of Justice (DOJ), Federal Bureau of Investigations (FBI), and Community Care Licensing (CCL) background clearance.
• Valid California Driver’s license.
• TB…