Quality & Compliance Specialist

The Quality & Compliance Specialist supports the hospital's quality improvement, regulatory compliance, and patient safety initiatives. This role is responsible for managing incident and adverse event reporting, coordinating patient grievance processes, ensuring timely external regulatory reporting, and collecting and analyzing data to support continuous performance improvement.

The specialist works collaboratively across clinical and administrative departments to promote regulatory readiness, patient safety, and compliance with federal, state, and accreditation standards.

Key Responsibilities

Incident & Adverse Event Management

• Monitor and manage daily incident and adverse event reports.
• Identify events requiring escalation and ensure timely follow-up.
• Document investigation processes, corrective actions, and resolution outcomes.
• Coordinate reporting to appropriate regulatory agencies in accordance with state and federal requirements.
• Support root cause analysis (RCA) and corrective action planning when applicable.

Patient Complaints & Grievances

• Receive, track, and manage patient complaints and grievances in accordance with hospital policy.
• Ensure timely acknowledgment and written response to grievances.
• Escalate high-risk concerns to leadership as appropriate.
• Maintain accurate documentation for compliance and regulatory review.

Regulatory & External Reporting

• Ensure compliance with reporting requirements for CMS, state health departments, and accrediting bodies (e.g., Joint Commission).
• Maintain documentation to support survey readiness and accreditation standards.
• Assist with preparation for regulatory inspections and audits.

Quality Improvement & Data Management

• Collect, clean, validate, and aggregate data from multiple departments.
• Develop reports and dashboards to monitor performance indicators.
• Support continuous quality improvement initiatives using performance data.
• Identify trends and areas for improvement and present findings to leadership.
• Participate in interdisciplinary quality committees as assigned.

Monday - Friday 9am-3pm