Quality Assurance and Compliance Coordinator

Updated: about 1 year ago
Location: Fort Collins, COLORADO
Deadline: 05 Feb 2023

Posting Details
Posting Detail Information


Working Title Quality Assurance and Compliance Coordinator
Position Location Fort Collins, CO
Work Location Position is fully in-office/in-person
Research Professional Position No
Posting Number 202300130AP
Position Type Admin Professional/ Research Professional
Classification Title Prof/Indiv Contrib II
Number of Vacancies 1
Work Hours/Week 40
Proposed Annual Salary Range $60,000 - $65,000; commensurate with experience and qualifications
Employee Benefits
Colorado State University (CSU) is committed to providing employees with a strong and competitive benefits package that supports you, your health, and your family. Visit CSU’s Human Resources website for detailed benefit plan information for permanent full-time and part-time faculty and administrative professional employees in the following University benefit areas: https://hr.colostate.edu/hr-community-and-supervisors/benefits/benefits-eligibility/ & https://hr.colostate.edu/prospective-employees/our-perks/ .
Desired Start Date
Position End Date (if temporary)
To ensure full consideration, applications must be received by 11:59pm (MT) on 02/05/2023
Description of Work Unit
Public Health and Risk Management
The Public Health and Risk Management department at the CSU Health Network focuses on ensuring measures are in place to comply with federal, state, and local regulations including the areas of compliance, quality and risk management, safety, and accreditation. In addition, this department supports CSU Health Network quality improvement initiates to maintain high standards of care. The Public Health and Risk Management department provides services between the hours of 8:00 am – 5:00 pm Monday-Friday, providing attractive work schedules for staff.
Quality Assurance and Compliance
The Training and Compliance Training department at the CSU Health Network takes a proactive approach to privacy, security, and training to support the highest quality of care. The department focuses on ensuring compliance measures are in place and met to comply with federal, state, and local regulations and law. This department also creates and coordinates onboarding and ongoing training for staff to ensure safety, awareness, accuracy and improve skills of all staff. The Training Compliance and Training department provides services between the hours of 8:00 am – 5:00 pm Monday-Friday, providing attractive work schedules for staff.
CSU Health Network
The CSU Health Network (CSUHN) at Colorado State University provides a full range of cost-effective mental health and primary care medical services on campus, referral for community specialty care, and comprehensive health education and prevention services programming. Services such as physical therapy, dentistry, and optometry are available. The CSU Health Network is active in creating a healthy campus environment to support learning and success. For more information about the CSU Health Network at Colorado State University, see http://www.health.colostate.edu.
Commitment to Campus – Why work at CSU?

Colorado State University’s Commitment to Campus encompasses a wide range of programs, discounts, and special benefits available to CSU faculty and staff. Here are just a few…
  • FREE credit courses (up to 9-semester credits per year) through Employee Study Privilege
  • FREE growth/training/development opportunities for Leadership, Personal Effectiveness, Communication & Conflict Resolution, Supervisory Skills, and Life and Wellness
  • FREE MAX transit use with CSU identification
  • After-school programs for kids
  • Tuition Scholarships up to 50% for eligible family members

For more Commitment to Campus programs, visit: https://commitmenttocampus.colostate.edu/ .
Retirement Programs
While employees of CSU do not contribute to Social Security, the University and the state of Colorado offer competitive retirement plans. As a condition of employment and required by Colorado law, employees are required to participate in either the University’s Defined Contribution Plan (DCP) or the Public Employee’s Retirement Plan (PERA) of Colorado. Each plan offers a generous employer match between 10% – 21%. For more information, visit: https://hr.colostate.edu/prospective-employees/our-perks/
Colorado State University

Colorado State University is one of the nation’s top public research universities and an institution on the rise. In the last decade, CSU has produced record enrollment, built on all-time highs in student diversity and student success; record fundraising far outpacing ambitious goals; groundbreaking research driven by a highly productive faculty; a campus revitalized by a transformational building campaign; and, perhaps most important, an unrivaled learning environment where nine of 10 recent graduates say they would choose CSU again and rate their education as excellent.
Colorado State University has a campus culture that is driven by a desire always to do better and a vision to be the best place to learn, work, and discover. Our Principles of Community – Inclusion, Integrity, Respect, Service, and Social Justice – reflect our core values and support CSU’s mission and vision of access, research, teaching, service, and engagement. Each member of our community has a responsibility to uphold these principles when engaging with one another and acting on behalf of the University.
CSU was recently ranked first among Colorado-based educational employers and fifth among all in-state employers in Forbes magazine’s “America’s Best Employers by State!”
Colorado State University is a tobacco and smoke-free campus. For the health of our university community, the use of smoking, vaping or tobacco products is prohibited on CSU grounds or in buildings.
Fort Collins
Fort Collins, which has been home to CSU since the University’s inception in 1870, is a vibrant, friendly city of 161,000 tucked against the foothills of the Rocky Mountains in Northern Colorado, just 60 miles from Denver. The city boasts a lively arts and cultural scene, shopping in historic Old Town, a strong economy, and is a haven for outdoor enthusiasts. With more than 200 miles of bike paths and trails, easy access to the scenic Poudre River and majestic Rocky Mountain National Park, and within easy driving distance of Colorado’s iconic ski areas, it is a year-round paradise. Boasting a mild climate, thriving high-tech industry, and some of the best microbreweries in the world, it’s no wonder Fort Collins annually ranks among the most livable small cities in the United States.
Position Summary
The Quality Assurance and Compliance Coordinator ensures that the policies and procedures of the CSU Health Network comply with the Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act (FERPA), accreditation standards of accrediting entities, and other federal, state, and local laws and regulations. This position is responsible for establishing compliance programs based upon best practices and federal or state guidelines, ensuring that software systems and technologies support the needs of compliance programs, and training CSU staff about these regulations and guidelines. This position participates in other programs within the CSU Health Network, including Safety, Quality Improvement, Risk Management, and Accreditation teams, and may have leadership/chair responsibility of assigned committees.
The position maintains professional knowledge in all areas of job duties by attending and participating in educational programs and by networking with colleagues. The position acts as a resource and mentor to co-workers by modeling professional and positive behaviors.
The Quality Assurance and Compliance Coordinator reports directly to the Director of Operations.
Required Job Qualifications
Education/Experience
  • Bachelor’s degree in healthcare administration, public health, law, business, nursing, or another applicable field, plus three years related experience in a health care environment in regulatory, compliance, quality assurance, accreditation, safety, and/or risk management capacity
Preferred Job Qualifications
Certification
  • Certification in healthcare compliance

Experience
  • Experience working in a college/university student healthcare environment
  • Experience working with diverse populations, including diverse religious/spiritual beliefs; racial, ethnic, and cultural backgrounds; and diverse sexual orientations and gender identities
  • Experience working on a multidisciplinary team

Knowledge, Skills, Abilities, and Other Characteristics
  • Mastery of communication, including listening, verbal, written, and presentation skills
  • Proven initiative in creating and maintaining programs to support organizational vision
  • Demonstrated ability to be a full-functioning, productive, and positive team member
  • Ability to analyze policies, programs, and initiatives to make recommendations for quality improvement
  • Strong problem solving and interpersonal relations skills
  • Ability to write and implement policies and procedures
  • A personal or professional commitment to diversity, equity, and inclusion through active planning and purposeful effort
Diversity Statement
Reflecting departmental and institutional values, candidates are expected to have the ability to advance the Department’s commitment to diversity and inclusion.

Essential Duties


Job Duty Category Compliance
Duty/Responsibility
  • Establishes compliance programs based on best practices and federal guidelines:
    • Develops, reviews, and updates Standards of Conduct.
    • Develops and oversees a system for handling violations of rules, regulations, policies, procedures and Standards of Conduct.
    • Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues; and provides general guidance on how to avoid or deal with similar situations in the future.
    • Establishes and provides direction and management of Compliance Hotline (where any person—patient or staff—may call to report a HIPAA violation, for example).
    • Institutes and maintains an effective compliance communication program.
    • Develops an effective compliance training program.
  • Serves as a primary resource for CSU Health Network staff for federal privacy law questions and concerns that involve HIPAA, FERPA or Colorado state laws.
  • Performs investigations in the case of a breach of information with periodic check-ins with supervisor to provide updates and/or ask for input during the investigation; contacts supervisor of breach of information and helps prepare for notification to the Federal Government
    • Routes any needed decision-making or resolution processes through the Director of Operations or Leadership Team.
  • Receives, reviews, and investigates compliance issues.
  • Develops and delivers security and privacy training for CSU Health Network staff, including orientation of new employees and business associates regarding compliance and patient confidentiality at the CSU Health Network.
  • Works with University legal counsel to ensure that CSU Health Network policies, consent and authorization forms, and business associate agreements are in compliance with applicable requirements and practice standards.
  • Conducts periodic privacy risk assessments and ongoing compliance monitoring activities in conjunction with University and CSU Health Network Information Technology departments.
  • Responds to questions about disclosure of medical records and works closely with CSU Health Network data custodians to ensure that public health information is handled appropriately.
  • Serves as site administrator for the UCHealth provider connection and monitors regular audits.
Percentage Of Time 20%
Job Duty Category Quality Improvement and Risk Management
Duty/Responsibility
  • Serves as a participant or Chair of the Quality Improvement Committee and provides support to the CSU Health Network quality improvement initiatives.
  • Assists the Director of Operations with the risk management program to meet standards established by CSU’s Health Network accreditation body.
  • Identifies CSU Health Network risk areas and implements programs, processes, and/or actions specifically designed to reduce organizational risk and liability, using established principles developed by the American Society for Healthcare Risk Management, for example:
    • Maintains data on occurrence reporting information.
    • Develops a process to assess and monitor patient and client complaints.
  • Creates annual risk management goals in response to identified risk patterns, for example:
    • Tracks occurrence report trends, which monitors adverse events, safety issues, medical care issues, or billing and coding concerns; based on these reports, high risk, high volume, or problem prone areas are identified and goals developed to address these concerns; these goals are presented to the QI Committee and Leadership Team each year.
    • Communicates goals to the Supervisor, Leadership Team and the QI Committee for input and approval.
  • Oversees the occurrence reporting process, including receiving, investigating, and providing appropriate resolution for reports submitted, noting patterns to be addressed, and facilitating operational or procedural changes as needed.
  • Oversees the service recovery process for student complaints or concerns.
Percentage Of Time 20%
Job Duty Category Policies and Procedures
Duty/Responsibility
  • Researches state and federal regulations, CSU system and campus policies, accreditation standards, and university best practices to assist in the development of CSU Health Network organizational policies.
  • Reviews and assesses organizational policies for accuracy and relevancy and revises existing policies, creates new policies, and/or sends policies to primary stakeholders for review.
  • Coordinates the needs and opinions of various stakeholders in developing policies, drafts policies for stakeholder review, and composes final policies for leadership approval.
  • Maintains CSU Health Network document management system (PowerDMS), archives policies, and ensures on-line policy information is current, organized, and accessible.
  • Educates all staff members regarding policy changes.
Percentage Of Time 20%
Job Duty Category Accreditation
Duty/Responsibility
  • Serves as the internal resource on the accreditation organization’s requirements for compliance with ambulatory health care standards.
  • Provides interpretation and analysis of the accreditation standards and develops and implements ongoing surveillance of all work units for compliance.
  • Evaluates organizational processes and determines action(s) needed by work units to be compliant with standards.
  • Designs, develops, and teaches educational programs on practical applications of the standards and how to meet them.
  • Collaborates to determine strategies for on-site surveys and serves as the organizational liaison with the accrediting organization.
Percentage Of Time 20%
Job Duty Category Safety
Duty/Responsibility
  • Serves as a participant or Chair of the Safety Committee.
  • Assists the Director of Operations with the patient and staff safety program that incorporates requirements of CSU Biosafety department and the standards prescribed by our healthcare accreditation body; examples of training are:
    • Conducts training for new employees on emergency management, use of plain language codes, responding to weather and emergency situations.
    • Completes a risk assessment each year related to current staff to determine training needs; training examples are: panic button usage, plain language codes used in an emergency and how to to respond to a tornado.
  • Serves as a resource for general safety-related issues and concerns, including identification of physical hazards that could impact patient or staff safety.
  • Provides staff training on safety and security.
  • Coordinates and oversees the CSU Health Network emergency planning efforts.
  • Develops a program to increase patient and client safety.
  • Coordinates CSU Health Network business continuity and disaster recovery plans in conjunction with campus emergency planning efforts.
  • Conducts emergency drills and exercises in accordance with accreditation requirements.
  • Serves as CSU Health Network representative for CSU and Larimer County Emergency Management coalition.
  • Ensures compliance with Hazardous Materials program.
Percentage Of Time 20%

Application Details


Special Instructions to Applicants
Applicants needing assistance to submit application materials may contact Serena Henson at [email protected].
Complete applications must include:
  • A cover letter addressing Required Job Qualifications, Preferred Job Qualifications and Essential Job Duties
  • Resume

For full consideration, complete applications must be received by 11:59 pm Mountain Time on Sunday, February 5, 2023. References will not be contacted without prior notification of candidates.
Conditions of Employment Pre-employment Criminal Background Check (required for new hires), Special Requirements/Other - Health Network follows CDC guidelines for Employee Health in a healthcare setting, including proof of vaccinations. Employees must show proof of compliance/willingness to comply by start date.
Search Contact Serena Henson, [email protected]
EEO Statement
Colorado State University is committed to providing an environment that is free from discrimination and harassment based on race, age, creed, color, religion, national origin or ancestry, sex, gender, disability, veteran status, genetic information, sexual orientation, gender identity/expression, or pregnancy in its employment, programs, services and activities, and admissions, and, in certain circumstances, marriage to a co-worker. The University will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. Colorado State University is an equal opportunity and equal access institution and affirmative action employer fully committed to achieving a diverse workforce and complies with all Federal and Colorado State laws, regulations, and executive orders regarding non-discrimination and affirmative action. The Office of Equal Opportunity is located in 101 Student Services.
The Title IX Coordinator is the Director of the Office of Title IX Programs and Gender Equity, 123 Student Services Building, Fort Collins, CO 80523-0160, (970) 491-1715, [email protected] .
The Section 504 and ADA Coordinator is the Director of the Office of Equal Opportunity, 101 Student Services Building, Fort Collins, CO 80523-0160, (970) 491-5836, [email protected] .
The Coordinator for any other forms of misconduct prohibited by the University’s Policy on Discrimination and Harassment is the Vice President for Equity, Equal Opportunity and Title IX, 101 Student Services Building, Fort Collins, Co. 80523-0160, (970) 491-5836, [email protected] .
Any person may report sex discrimination under Title IX to the Office of Civil Rights, Department of Education .
Background Check Policy Statement
Colorado State University strives to provide a safe study, work, and living environment for its faculty, staff, volunteers and students. To support this environment and comply with applicable laws and regulations, CSU conducts background checks for the finalist before a final offer. The type of background check conducted varies by position and can include, but is not limited to, criminal history, sex offender registry, motor vehicle history, financial history, and/or education verification. Background checks will also be conducted when required by law or contract and when, in the discretion of the University, it is reasonable and prudent to do so.


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