Overview

The Clinical Compliance Coordinator will assist Corporate Compliance leadership in administering the organization's Compliance and Privacy Program by conducting audits, compliance rounding, regulatory research, education, policy and procedure development, investigative support, and corrective action monitoring. Supports HIPAA Privacy and drug diversion auditing and monitoring activities while promoting compliance with applicable laws, regulations, accreditation standards, and organizational policies

Responsibilities

Compliance Auditing and Monitoring

Performs clinical compliance audits based on professional nursing knowledge and expertise.

Conducts audit fieldwork and testing in a competent, objective, and professional manner.

Prepares detailed audit work papers in accordance with established audit programs, professional standards, and regulatory requirements.

Assists in identifying compliance risks and developing practical, effective recommendations to address audit findings.

Drafts audit reports, ensuring objectives are achieved, conclusions are supported by evidence, and recommendations are clear, concise, and actionable.

Monitors and tracks corrective action plans resulting from compliance audits and monitoring activities.

Participates in the development and execution of annual compliance risk assessments and audit plans.

Policy and Procedure Management

Assists with the development, review, revision, and implementation of organizational policies and procedures to ensure compliance with applicable laws, regulations, accreditation standards, and organizational objectives.

Collaborates with operational and clinical leaders to ensure policies and procedures are current, effective, and aligned with regulatory requirements and best practices.

Maintains documentation related to policy review and revision activities.

Compliance Rounding and Monitoring

Conducts compliance rounding activities throughout the organization to assess adherence to regulatory requirements, organizational policies, and compliance program expectations.

Identifies potential compliance risks, operational concerns, and opportunities for process improvement through routine rounding and monitoring activities.

Collaborates with department leaders and staff to promote awareness of compliance requirements and best practices.

Documents observations, findings, and trends identified during rounding activities and communicates appropriate concerns to leadership.

Coordinates and monitors corrective action plans related to findings identified through compliance rounding, monitoring activities, audits, and reviews to ensure timely resolution and sustained compliance.

Education and Training

Develops, coordinates, and delivers compliance-related education and training programs based on regulatory changes, organizational needs, and identified compliance risks.

Conducts Compliance and HIPAA Privacy education during new employee orientation.

Provides department-specific compliance and HIPAA Privacy training as assigned.

Privacy, Drug Diversion, and Investigative Support

Assists with HIPAA Privacy investigations in coordination with the HIPAA Privacy Officer, including fact gathering, documentation review, and follow-up activities.

Supports drug diversion auditing, monitoring, and investigative activities in collaboration with appropriate clinical, pharmacy, compliance, and operational leadership.

Assists in identifying trends, risks, and potential areas of noncompliance related to privacy and drug diversion prevention efforts.

Participates in HIPAA Privacy walkthroughs and monitoring activities to assess compliance with privacy regulations, organizational policies, and established controls.

Assists in developing and monitoring corrective action plans related to findings identified through HIPAA Privacy reviews, drug diversion audits, investigations, monitoring activities, and other compliance assessments.

Maintains appropriate documentation and confidentiality related to investigations, audits, monitoring activities, and corrective action efforts.

Regulatory Compliance and Research

Proactively monitors and researches state and federal laws, regulations, guidance, and industry trends affecting healthcare operations and compliance programs.

Communicates regulatory updates and compliance requirements to affected departments and stakeholders.

Assists with the interpretation and application of laws, regulations, organizational policies, procedures, and ethical standards.

Researches compliance and regulatory issues and provides analysis and recommendations as requested.

Supports compliance investigations involving alleged, suspected, or reported violations of applicable laws, regulations, policies, or standards.

Reporting and Collaboration

Communicates routinely with organizational leadership regarding compliance activities, emerging risks, audit outcomes, and issues requiring immediate attention.

Assists with compliance-related employee interviews, surveys, and investigations as directed.

Collaborates with department leaders and staff to promote a culture of compliance, integrity, and accountability throughout the organization.

Administrative and Professional Responsibilities

Maintains strict confidentiality of sensitive information, audit records, investigations, and other department activities.

Maintains performance, patient satisfaction, employee satisfaction, and financial standards as outlined in performance expectations.

Complies with all requirements outlined in the Employee Handbook and Code of Conduct.

Adheres to organizational behavioral standards and fosters positive relationships with patients, families, coworkers, and leadership.

Utilizes required technology and software systems, including email, timekeeping systems, learning management systems, and organizational intranet resources.

Complies with all organizational policies, procedures, and regulatory requirements.

Performs other duties as assigned.

Qualifications

High school diploma or equivalent required; nursing licensure is required.
Experience in healthcare operations, healthcare auditing, consulting, regulatory compliance, investigations, and the identification and resolution of systemic operational issues is preferred.
Certification in Healthcare Compliance (CHC) or a related compliance credential is preferred.
Demonstrated ability to manage multiple priorities simultaneously while maintaining a high degree of accuracy and attention to detail in a fast-paced, deadline-driven environment.
Strong interpersonal skills with the ability to collaborate effectively across diverse, multidisciplinary teams.
Advanced proficiency with computer systems, internet-based applications, and related technologies is required.
Experience with Mediregs compliance software is preferred.
Must be able to read, write legibly, speak, and comprehend English.

WORKING CONDITIONS

WORK CONTEXT

Interpersonal Relationships – Daily contact with others through face-to-face discussions, electronic mail, and telephone. Frequently coordinates and leads others, works with a group or team, deals with internal and external customers (including occasional unpleasant or angry people), participates in conflict situations/resolutions, produces results, and draft letters, memos and reports to document activities.
Physical work conditions – Works primarily indoors in a controlled environment sitting at a computer or workstation.
Structural job characteristics – Regular work schedules with occasional requirements to be available to accommodate employees on other shifts. High degree of freedom to make decisions that affect other people, as well as the image and reputation of the organization. Extremely important to be exact and accurate based on the seriousness/consequence of errors.

PHYSICAL FACTORS

Ability: The ability to bend, stretch, twist, or reach with your body, arms, and/or legs.
Activities: Talking, hearing, bending, twisting, walking, kneeling, crouching, stooping, reaching, pushing, pulling, lifting, grasping, repetitive motion, standing, and/or using hands to handle, control, or feel objects, tools or controls.
Requirements: Sedentary work. Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Involves sitting most of the time. Walking and standing are required only occasionally and all other sedentary criteria are met.
Must be able to perform the duties with or without reasonable accommodation.
Hearing and vision must be normal or corrected to within normal range.
Physical presence onsite is essential.

OTHER JOB FACTORS

Requires the following cognitive abilities: deductive and inductive reasoning, flexibility of closure, fluency of ideas, information ordering, mathematical reasoning, memorization, number facility, oral comprehension and expression, originality, problem sensitivity, selective attention, speed of closure, time sharing, visualization, and written comprehension and expression.
Requires the following psychomotor abilities: finger and manual dexterity.
Requires the following sensory abilities: speech clarity and recognition.
Requires the following personal characteristics/work styles: integrity, initiative, leadership, dependability, achievement/effort, adaptability/flexibility, analytical thinking, concern for others, cooperation, independence, innovation, persistence, self control, social orientation, stress tolerance and attention to detail.
Position satisfies each of the following work values: achievement, independence, recognition, relationships, support, and good working conditions.

KEY WORD SEARCH

Clinical Compliance

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