Job Summary:

The Compliance Coordinator has oversight over regulatory compliance, quality and infection control related activities, safety and emergency preparedness and clinical education. This role ensures compliance with federal, state, CMS, and accreditation standards while promoting patient safety, quality outcomes, and preparedness for emergencies. The position collaborates with clinical leadership, administrators, and regulatory agencies to support continuous performance improvement and organizational readiness.

Supervisory Responsibilities:

Does not oversee other staff

Duties/Responsibilities:

Regulatory Compliance:

• Lead mock surveys and center assessments, prepare responses and corrective action plans as necessary
• Oversees organizational compliance with federal, state, local, CMS, and accreditation standards.
• Conducts audits, monitoring, and risk assessments to maintain regulatory readiness.
• Develops, reviews, and maintains policies and procedures supporting compliance.
• Coordinates accreditation surveys and serves as liaison with regulatory agencies.
• Monitor changes in state and federal law, assessing impact on ASC operations, and communicate changes to leadership.
• Provides compliance education and maintains required documentation.
• Ensures with CMS, CDC, OSHA, state, local and accreditation requirements.

Clinical Education Coordinator:

• Facilitate and manage the onboarding process for new clinical employees, ensuring completion of all orientation pathways and skills checklists within required timelines.
• Develop, update, and implement annual high-risk clinical competencies for all staff to ensure compliance with regulatory standards (e.g., AAAHC, CMS, The Joint Commission).
• Provide or organize in-service education on new technology, equipment, and surgical techniques. Partners with clinical leadership to ensure annual education plans and staff competencies align with regulatory requirements and are completed on time.
• Organize and coordinate clinical in-services and regulatory drills, including annual Code Blue, Malignant Hyperthermia, and fire safety drills.
• Analyze educational outcomes and audit patient care to identify areas for improvement. Work closely with the Quality Management team to address deficiencies.
• Assist in creating, reviewing, and updating perioperative policies and procedures to reflect current evidence-based practices.
• Act as the primary liaison between clinical leadership, medical staff, and external trainers/vendors.
• Monitors, tracks, and assists with organizing in-services and staff education.
• Provides education, consultation, and committee coordination related to infection prevention.
• Provides education, consultation, and committee coordination related to safety and emergency preparedness.

Quality / Infection Control / Performance Improvement:

• In coordination with the Quality Coordinator, supports the Center’s on-site quality management and performance improvement activities.
• Coordinates quality-related data collection, analysis, reporting, and committee functions.
• Supports quality reporting requirements, including ASC Quality Reporting measures.
• Identifies trends and recommends improvements to enhance patient safety and outcomes.
• Assists with and maintains the Infection Prevention and Control program, including surveillance and reporting.
• Participates with infection risk assessments and investigation with identified infections.
• Completes required public health reporting and documentation.

Safety / Emergency Preparedness:

• Develops and maintains emergency management and safety programs.
• Develop and maintain all-hazards plans, policies and procedures.
• Conducts hazard vulnerability assessments, drills, and training.
• Identify potential threats and ensure resources are in place.
• Work with local law enforcement, emergency management agencies and public health officials as needed.
• Know the organization’s alert and notification system and procedures, and ensure appropriate staff is educated on this as well.
• Establish a schedule of training and exercises to practice/ test the emergency plans and participate with community partners in community or statewide exercises.
• Document the results of these exercises in an after-action report to improve the facility’s emergency operations plan and response activities. Incorporate any lessons learned into future iterations of the plans.
• Coordinate and meet with department leaders from the organization to work on corrective action plans, and improvement initiatives related to safety and emergency management programs.
• Conducts and coordinates monthly safety meetings.
• Monitors, organizes, and documents weekly, monthly, quarterly, and annual drills in accordance with regulatory and accrediting requirements.
• Ensures compliance with CMS, OSHA, NFPA, DHS, and accreditation standards.
• Coordinates emergency documentation, community collaboration, and after-action reviews.

Other functions/duties:

• Promotes patient, physician and employee safety and satisfaction. 
• Promotes patient, and physician satisfaction.
• Recognizes and defines problems, collects data, establishes facts, draws valid conclusions, and corrects errors.

• Adheres to safety policies and practices good body mechanics and ergonomics.
• Follows all rules and regulations for PHI and HIPAA protections of patient information.
• Follows all policies and procedures, including, but not limited to, attendance, timeliness, and safeguarding confidential information.
• Reports incidents in a timely manner.
• Promotes patient and employee safety and communicates concerns appropriately, following Chain of Command.
• Attends in-service programs as requested
• Performs other related duties as directed

Required Skills/Abilities:

• Comprehensive and current knowledge of general nursing theory and practice, including basic disciplines, relating to nursing such as biological, physical, social and medical sciences and their application to patient care.

• Knowledge of surgical procedures, techniques, symptoms and complications of surgery, anesthesia and consequent nursing interventions. 

• Strong knowledge of adult education principles and teaching techniques. 
• Deep understanding of sterile technique, perioperative service lines, and patient safety. 
• Maintains current knowledge of infection control standards and practices (AORN, APIC, AAMI, CDC, SGNA). 
• Proficiency in Learning Management Systems (LMS), electronic health records (EHR), and Microsoft Office Suite. 
• Highly organized with the ability to manage multiple projects and meet tight regulatory deadlines. 
• Demonstrates strong collaboration, organization, and problem-solving skills. 
• Exceptional verbal and written communication skills with the ability to interact with a diverse population professionally. The ability to effectively interact and communicate with all levels within Bend Surgery Center and external customers, clients and potential employees.

• Demonstrated ability to lead meetings, deliver presentations and mentor staff.

• Must be able to problem solve and execute resolution; able to recognize needs, implement changes and evaluate impact.
• Must be organized, flexible and versatile with the ability to function effectively in stressful situations.
• Ability to understand, read, write, and speak English. Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to successfully write business correspondence. Ability to effectively present information, respond to questions, and professionally interact with managers, employees, clients, vendors, and the general public.

Education and Experience:

• Graduate of an accredited school of nursing and currently licensed to practice as a Registered Nurse in the State of Oregon.
• 3-5 years of perioperative nursing experience (Operating Room or PACU) in an Ambulatory Surgery Center or similar surgical setting required, with prior experience with educating teams or precepting preferred.
• Experience with education, safety, healthcare emergency preparedness, quality assurance, infection prevention, and regulatory compliance preferred.

**Lifting more that 50lbs requires an assistive device and or additional physical assistance.

*Position is Full-Time, 40hr/week*

Stated salary in posting is the full salary range. Hiring salary cap is limited to mid-point of $57.04-$59.88.