Quality and Risk Specialist

Description

The Quality/Risk Management Coordinator supports the hospital’s quality improvement, patient safety, regulatory compliance, accreditation readiness, and risk management programs. This position serves as an operational and administrative extension of the Vice President of Regulatory Risk & Professional Practice Development and assists with day-to-day coordination of quality, patient safety, survey readiness, and regulatory activities across the organization.

Full-time

The Quality/Risk Management Coordinator supports the hospital’s quality improvement, patient safety, regulatory compliance, accreditation readiness, and risk management programs. This position serves as an operational and administrative extension of the Vice President of Regulatory Risk & Professional Practice Development and assists with day-to-day coordination of quality, patient safety, survey readiness, and regulatory activities across the organization.

The coordinator works collaboratively with nursing leadership, medical staff, department directors, and operational teams to promote continuous survey readiness, performance improvement, patient safety, and organizational compliance with CMS, Critical Access Hospital (CAH), and accreditation standards.

This role is designed to provide operational support for quality and risk initiatives while allowing executive leadership to focus on physician relations, strategic initiatives, regulatory oversight, and organizational operations.

• Coordinate and support hospital-wide Quality Assurance and Performance Improvement (QAPI) activities.
• Assist departments with performance improvement initiatives, corrective action plans, and follow-up monitoring.
• Track organizational quality metrics, dashboards, and regulatory indicators.
• Assist with collection, validation, trending, and reporting of quality and patient safety data.
• Support implementation and monitoring of process improvement initiatives.
• Maintain action plan trackers and ensure accountability for assigned deliverables.

• Coordinate the hospital’s incident reporting and event management processes.
• Review occurrence reports and elevate high-risk concerns to leadership.
• Assist with preliminary investigations of adverse events, near misses, grievances, and patient safety concerns.
• Coordinate follow-up documentation and maintain risk management logs and tracking systems.
• Assist with Root Cause Analyses (RCA), focused reviews, and risk mitigation activities.
• Monitor trends and identify opportunities for operational and clinical risk reduction.

• Assist with ongoing readiness for CMS, The Joint Commission, Critical Access Hospital Conditions of Participation, & state regulatory requirements.
• Coordinate survey readiness activities including tracers, mock surveys, rounding, & compliance audits.
• Assist with maintaining regulatory documentation, evidence binders, & accreditation readiness materials.
• Track regulatory findings, corrective action plans, & sustainability monitoring.
• Support policy review & revision processes to ensure regulatory alignment.

• Prepare agendas, reports, dashboards, committee minutes, & executive summaries for quality, safety, & regulatory meetings.
• Coordinate meeting follow-up items & maintain tracking tools for organizational initiatives.
• Assist with peer review tracking, FPPE/OPPE administrative support, & provider quality documentation.
• Maintain confidential quality & risk management files in accordance with regulatory & legal requirements.
• Support special projects & organizational initiatives assigned by executive leadership.

• Assist with staff education related to patient safety, event reporting, regulatory compliance, & quality improvement.
• Collaborate with department leaders to improve compliance, documentation, & operational workflows.
• Promote a culture of safety, accountability, & continuous improvement across the organization.
• Serve as a resource to departments regarding quality & risk management processes.