Clinical Quality & Compliance Coordinator

Edenbridge Health Llc•Washington, DC

2d•Hybrid

About The Position

The Clinical Quality and Compliance Coordinator supports the implementation, monitoring, and continuous improvement of the Quality Improvement Program (QIP) and Compliance Plans within the PACE Organization (PO). This role helps ensure compliance with all Centers for Medicare & Medicaid Services (CMS), federal, state, and local regulatory requirements. The Coordinator promotes standardized processes, quality of care, regulatory compliance in clinical and operational practices, and the collection and analysis of data to support organizational quality improvement goals and regulatory performance standards.

Requirements

Bachelor’s degree in Nursing or a related healthcare field required.
Minimum of one (1) year of documented experience working with a frail or elderly population preferred.
Minimum of three (3) years of nursing leadership or healthcare quality experience, with demonstrated experience in: Quality improvement and performance improvement initiatives Regulatory compliance and healthcare auditing Process improvement and corrective action implementation Data collection, analysis, and reporting Facilitation of interdisciplinary workgroups and committees
Must be action-oriented, have business acumen, manage conflict well, be customer focused, have high decision quality, flexibility to adapt to ongoing change and have organizational agility. Ability to work with minimal supervision and exercise independent judgment.
Possess interpersonal skills to drive collaboration, commitment and productivity when working with cross-functional teams, customers and end users. Must be comfortable functioning in a virtual, collaborative shared leadership environment.
Demonstrates superior written and verbal communication and presentation skills appropriate for audience comprehension. Well-developed communication skills, both written and oral, that may be used either in an on-site or virtual environment is required. Able to communicate effectively with individuals and groups representing diverse perspectives.
Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic knowledge and experience with electronic mail and calendaring system. Ability to type with speed and accuracy. Ability to use other software as required to perform the essential functions of the job.
Possesses a high degree of personal accountability, responsibility and independent decision making abilities with the skills to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures of the organization in line with the mission, vision, and philosophy of Edenbridge PACE.
Excellent organizational skills. Ability to perform multiple duties and functions related to daily operations and maintain excellent customer service skills. Ability to perform frequent detailed tasks and provide immediate service with frequent interruptions. Ability to change and be flexible with work priorities. Strong problem solving skills.
Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical and experience based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize workload.

Responsibilities

Support the implementation and monitoring of the organization’s Quality Improvement Program (QIP) and Compliance Program in accordance with PACE regulations and organizational performance goals.
Assist with maintaining compliance with all applicable federal, state, and local laws, regulations, and PACE program requirements.
Support activities necessary to obtain and maintain certification with CMS and other regulatory agencies.
Maintain up-to-date knowledge of healthcare regulations, compliance standards, and organizational policies to ensure ethical and professional conduct.
Develop, implement, and monitor performance improvement projects based on quality performance measures, audit findings, and identified operational needs.
Lead or support Root Cause Analysis (RCA) activities to identify systemic issues and drive continuous improvement initiatives.
Develop and manage Plans of Correction (POC) in response to quality improvement findings, regulatory surveys, and audit outcomes.
Assist staff and leadership with process evaluations and performance improvement initiatives.
Develop and implement internal audits to ensure adherence to established policies, procedures, and clinical protocols.
Support preparation for CMS and state regulatory surveys, site visits, and inspections.
Maintain continuous survey readiness through ongoing monitoring and audit activities.
Participate in routine internal and external audits and support corrective action implementation.
Collect, analyze, and report quality and compliance data to monitor performance and support regulatory reporting requirements.
Prepare and submit monthly quality metrics reports and other required reports to CMS, state agencies, and internal leadership.
Assist in preparing the Interdisciplinary Team (IDT) for monthly and quarterly reporting and regulatory meetings with CMS and state regulators.
Support the Infection Control Program by collecting and analyzing infection-related data.
Investigate infection control concerns and serve as a resource for infection prevention and control practices.
Assist with the development, review, and maintenance of organizational policies and procedures to ensure regulatory compliance and alignment with best practices.
Monitor complaints, service delivery requests, grievances, and appeals to ensure appropriate investigation, timely resolution, regulatory compliance, and identification of trends to support quality improvement initiatives.
Ensure compliance with incident reporting requirements and perform trend analysis to identify improvement opportunities.
Support the development of action plans and quality improvement initiatives based on identified trends.
Participate in the Quality Improvement Committee and Sub-committees in collaboration with the Medical Director and the Director of Quality & Compliance.
Assist with preparing meeting agendas, minutes, reports, and presentation materials.
Communicate quality improvement initiatives and performance outcomes to staff, leadership, contractors, and the Participant Advisory Committee (PAC)
Promote collaboration across departments to support quality and compliance initiatives.
Conduct routine quality assurance reviews of medical coding (ICD-10, CPT, HCPCS) to ensure accuracy, completeness, and compliance with CMS, PACE, and organizational guidelines.
Validate that clinical documentation supports assigned codes and meets regulatory and reimbursement requirements.
Identify coding discrepancies, trends, and potential compliance risks, and escalate findings as appropriate.
Identify missed, undercoded, or overcoded conditions and provide recommendations to ensure complete and compliant documentation of participant health status.
Collaborate with clinical staff, providers, and coding personnel to clarify documentation and improve coding accuracy.
Provide feedback, education, and guidance to staff on coding standards, documentation requirements, and best practices.
Support internal and external coding audits and assist in the development and implementation of corrective action plans related to coding errors or deficiencies.
Monitor coding-related quality metrics and contribute to performance improvement initiatives.
Stay current with changes in coding regulations, CMS guidance, and industry standards to ensure ongoing compliance.
Monitor participant satisfaction data and grievance trends within the PACE center.
Support oversight of quality performance within contracted facilities.
Maintain strict confidentiality of participant information in accordance with HIPAA and organizational policies.
Attend and participate in staff meetings, training sessions, committees, and special projects as assigned.
Foster a collaborative work environment by building positive relationships, facilitating teamwork, and resolving conflicts when necessary.