Coordinator: Regulatory Compliance and Quality Improvement (On-site with Hybrid Flexibility)

About the position Pagosa Springs Medical Center (PSMC) is seeking a detail-oriented Regulatory Compliance and Quality Improvement Coordinator to support the organization’s compliance, regulatory readiness, and quality improvement programs. Working under the direction of the Director of Compliance, Privacy and Quality, this position assists in monitoring and maintaining compliance with federal and state regulations, Conditions of Participation, and contractual obligations. The Coordinator collaborates with departments across the organization to conduct audits, monitor corrective actions, support regulatory readiness, and strengthen organizational quality and risk management efforts. This role requires strong analytical skills, sound judgment, and the ability to manage complex interdisciplinary projects. Join a Hospital That Feels Like Family – In a Town That Feels Like Home Pagosa Springs Medical Center is an award-winning, independent Critical Access Hospital serving the residents and visitors of Archuleta County and the surrounding region. As a modern rural hospital, PSMC delivers exceptional emergency, primary, and specialty care supported by advanced technology, a collaborative medical staff, and a leadership team committed to quality, safety, and patient-centered service. At PSMC, you are not just a number – you are a valued team member whose contributions make a real difference. We prioritize professional growth, meaningful work, and a positive, supportive workplace culture grounded in our WISER values: Wholeness, Integrity, Stewardship, Excellence, and Respect. What you’ll find at PSMC: A supportive, collaborative culture where people truly care about each other Modern facilities and growing service lines Leadership that listens and invests in staff Opportunities to learn, grow, and advance your career A place where you can have direct impact on patient care and community wellness Live Where Other People Vacation Pagosa Springs is a mountain paradise tucked among the rugged peaks of the San Juan National Forest. Here, you can step into nature the moment you clock out: Relax in our world-famous hot springs Ski or snowboard at Wolf Creek Ski Area – “the most snow in Colorado,” just 30 minutes away Explore hundreds of miles of hiking, biking, and off-roading trails Enjoy fly fishing, rafting, or paddle boarding on pristine rivers and lakes Experience warm, friendly community with local festivals, live music, farmers markets, and small-town charm If you’re looking for meaningful work, work-life balance, and a community that embraces you – PSMC and Pagosa Springs are the perfect place to build your future.

Responsibilities

• Assist in developing and implementing auditing and monitoring plans
• Conduct compliance audits and regulatory readiness assessments
• Track corrective action plans and follow-up activities resulting from audit findings
• Support regulatory inspections and inquiries from government agencies
• Monitor updates to healthcare regulations and assist with policy updates
• Collaborate with the quality department to support regulatory and quality initiatives
• Assist in preparing compliance reports and summaries for leadership
• Support risk assessments and compliance investigations
• Monitor and track implementation of quality improvement actions
• Conduct federal and state exclusion monitoring using systems such as OIG LEIE, SAM, and state Medicaid exclusion lists
• Investigate potential vendor matches and coordinate resolution plans
• Generate exclusion monitoring reports for leadership and regulatory review
• Provide education to staff involved in vendor management processes
• Provide support to the Compliance Officer and Compliance Committee
• Assist with internal audit preparation and documentation
• Coordinate meetings, agendas, and committee documentation
• Maintain compliance documentation and records

Requirements

• Associate’s or Bachelor’s degree in a healthcare-related field preferred (Compliance, Law, Healthcare Administration, Risk Management, or similar)
• Experience working in a healthcare setting preferred
• Familiarity with quality assurance, compliance, or risk management processes
• Demonstrated ability to manage complex interdisciplinary projects
• Strong analytical and auditing skills
• Knowledge of regulatory and compliance processes in healthcare
• Excellent organizational and project management abilities
• Proficiency in Microsoft Office and project management tools
• Strong written and verbal communication skills
• Office-based hospital environment
• Hybrid schedule with on-site collaboration required
• Frequent interaction with staff, leadership, vendors, and regulatory stakeholders
• Light physical work with extended periods of computer use

Nice-to-haves

• Certified Professional Medical Auditor (CPMA)
• Certified Internal Auditor (CIA)
• Certification in Risk Management Assurance (CRMA)
• Certification in Healthcare Compliance (CHC)
• Certified Compliance & Ethics Professional (CCEP)

Benefits

• Benefits include generous paid time off, separate sick leave, health, dental, vision, life and AD&D insurance, long-term disability and option for short-term disability, and retirement plan with employer contribution.

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