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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.

Quality Improvement & Performance Improvement

• 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.

Risk Management & Patient Safety

• Coordinate the hospital’s incident reporting and event management processes.
• Review occurrence reports and escalate 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.

Regulatory & Accreditation Readiness

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

Administrative & Operational Support

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

Education & Collaboration

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

Required Qualifications

• Bachelor’s degree required.
• Current Registered Nurse (RN) license required.
• Minimum of three (3) years of healthcare experience required.
• Experience in quality improvement, accreditation, compliance, patient safety, or risk management preferred.
• Critical Access Hospital or rural healthcare experience preferred.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) preferred.
• Experience with CMS Conditions of Participation, The Joint Commission, or Critical Access Hospital standards preferred.
• Certification in Healthcare Quality (CPHQ), Patient Safety (CPPS), or Healthcare Risk Management (CPHRM) preferred.
• Experience with incident reporting systems, regulatory surveys, and performance improvement methodologies preferred.

Knowledge, Skills, and Abilities

• Knowledge of hospital regulatory and accreditation standards.
• Strong organizational and project coordination skills.
• Ability to manage multiple priorities and deadlines simultaneously.
• Strong analytical and critical thinking skills.
• Excellent written and verbal communication abilities.
• Ability to maintain confidentiality and exercise professional judgment.
• Proficiency with Microsoft Office applications and healthcare reporting systems.
• Ability to work collaboratively across departments and leadership levels.

Physical Requirements

• Prolonged periods of sitting, standing, and computer work.
• Ability to travel throughout hospital departments.
• Ability to occasionally lift up to 25 pounds.

Work Environment

This position operates in both clinical and administrative healthcare settings and requires interaction with leadership, providers, staff, patients, and regulatory agencies as needed. The role involves handling confidential and sensitive information and supporting time-sensitive organizational priorities.