Quality & Compliance Coordinator

Quality & Compliance Coordinator

This role supports the Quality & Compliance team and coordinates cross-functionally by performing administrative, regulatory, and project-based activities across the department and the ASCs, while contributing to quality, and compliance initiatives.

The coordinator serves as a key point of coordination for ASC regulatory readiness, policy and contract administration, document control, and continuous improvement, working closely with quality, compliance, and legal leadership and maintaining a high degree of confidentiality.

Responsibilities

Provides administrative and coordination support to the Quality & Compliance department maintaining a high degree of confidentiality

Assists with the preparation and creation of quarterly QAPI reports

Assists with Peer Review assignment distribution, tracking, and creating reports

Processes incident reports for insurance claims and coordinates related follow-up activities

Maintains QAPI training completion records and performs follow-up as needed

Coordinates quarterly THCIC reporting for Texas ASCs, ensuring accurate data submission, timely filing, and compliance with all Texas Health Care Information Collection (THCIC) requirements

Assists Sr. Director of Quality with the Merit-based Incentive Payment System (MIPS) performance monitoring, data validation, provider updates and staff follow-up

Tracks meeting dates and updates applicable reports and documents accordingly

Assists with report creation and data entry within the Compliance Line (myMCM) platform

Processes form translation requests for the department

Assists with compliance monitoring activities as needed by the Compliance Manager

Updates surgical forms changes including editing grammar, punctuation, or spelling as needed. This requires knowledge of healthcare vocabulary and limited range of specialized terminology

Assists with preparation for surveys (AAAHC, CMS), serves as the AAAHC database contact person and maintains required documentation

Following pre-determined format, reviews each ASC's Medicare Survey Book to verify accuracy, completeness and alignment with current CMS requirements, ensuring all documents, policies, and supporting evidence are updated and ready for surveyor review

Coordinates with the department leaders and the ASC Regulatory Specialist (or similar role) on necessary updates to policies and procedures, maintaining version control, and ensuring all documents remain current and properly archived; requires strong proficiency in the MedTrainer platform for policy updates, tracking, and distribution

Coordinates Infection Control training for the ASC Managers and Directors

Provides support for CSOS (Controlled Substance Ordering System) by coordinating with the Procurement department to ensure compliant and timely procurement of controlled substances

Monitors all Unplanned Hospital Transfers to confirm required documentation is complete, accurate, and submitted, ensuring timely follow-up and compliance with ASC reporting standards

Ensures ASC regulatory filings are coordinated and completed timely cross-departmentally

Performs other duties as assigned

Qualifications

Education:

High school diploma or equivalent

Associate's degree or equivalent experience preferred; coursework or experience in healthcare administration, compliance, ASC regulations and survey requirements, or a related field is a plus

Experience:

Good knowledge of basic legal and regulatory requirements and procedures in the healthcare setting

Demonstrates ability to support compliance functions, including handling confidential and privileged information with discretion

Strong organizational and project-coordination skills, with the ability to manage multiple priorities, deadlines, and stakeholders independently

Familiarity with contract administration, policy management, and document/version control systems (e.g., MedTrainer)

Excellent oral and written communication skills

Excellent clerical and administrative skills

Ability to present a professional image of the department to consumers, the public, staff and Board at all times

Highly self-motivated, flexible, and direct, with the ability to work cooperatively with others as a productive team member

Excellent communication skills, written and verbal, with a high standard of positive interaction with all team members, clinic employees, clients, and members of the community

Ability to support a work team by demonstrating a positive attitude, openness to change, willingness to help cross-departmentally, and respect for others and their ideas

Ability to maintain a positive, solution-focused demeanor when responding to conflicts or problems

General computer proficiency, including accurate typing and proficiency in the Microsoft Office Suite

Benefits & Perks

Your health, happiness and your future matters! At AVP, we offer everything from medical and dental insurance, significant eye care discounts, child care assistance, pet insurance, continuing education funds, 401(k), paid holidays, PTO, Sick Time, opportunity for growth, and much more!