Quality Assurance and Compliance Coordinator

Colorado State University
Fort Collins, Colorado, United States
08 Apr 2018
End of advertisement period
06 May 2018
Contract Type
Full Time

Description of Work Unit

Colorado State University

Colorado State University is a public research university founded in 1870 and located in Fort Collins, in the U.S. state of Colorado. The university is the state’s land-grant university, and the flagship university of the Colorado State University System. As a land-grant institution, it is in the DNA of Colorado State University to promote education to anyone with the motivation and ability to earn a degree.

Our State is Colorado, but our Colorado State University Rams are built on a global scale. We unite in Fort Collins, where our diverse backgrounds, cultures, and experiences strengthen our community. Fort Collins is a community that blends education and industry, hard work and recreation, tradition and progress. True to our land-grand beginnings, we’re focused on practical solutions for today and tomorrow.

Colorado State University employs over 7,000 full and part-time faculty, exempt and non-exempt professionals, and classified staff. The current enrollment is approximately 33,058 students, including resident and non-resident instruction students. The University has approximately 2,000 faculty in eight colleges and 55 academic departments. Colorado State University, also known as CSU, offers more than 150 degrees in eight colleges. Bachelor’s degrees are offered in 65 fields of study, with master’s degrees in 55 fields. Colorado State confers doctoral degrees in 40 fields of study, in addition to a professional degree in veterinary medicine.

CSU Health Network

The CSU Health Network 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.

Public Health and Risk Management Department

The Public Health and Risk Management Department takes a proactive approach to privacy, security, and safety to support the delivery of high quality healthcare, and ensures compliance with accreditation standards and federal, state, and local laws and regulations.

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.

The Quality and Compliance Coordinator reports directly to the Public Health and Risk Manager.

CSU offers full benefits which include Medical, Dental, Vision, Life Insurance, Flexible Spending Accounts, retirement programs and more. The University’s Commitment to Campus benefits program offers a wide range of programs, discounts and special benefits available to eligible faculty and staff. For more detailed information about CSU benefits, visit http://www.hrs.colostate.edu/benefits/ and http://www.hrs.colostate.edu/benefits/fap-insplans-new.pdf.

Required Job Qualifications

  • Bachelor’s degree from an accredited college or university
  • Two years of progressive experience in direct patient care or health care administration

Preferred Job Qualifications


  • Advanced degree in healthcare administration, public health, law, business, nursing, or other applicable field
  • Certification in healthcare compliance


  • Three years of progressive experience in an ambulatory healthcare environment in a regulatory compliance, quality assurance, and/or risk management capacity
  • Experience working in a college/university student healthcare environment

Knowledge, Skills, Abilities and Other Characteristics

  • Mastery of communication, including listening, written, verbal, 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

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 an 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 the Federal Government to notify of breach of information.
  • 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 UC Health’s provider connection, and monitors regular audits.

Percentage Of Time 25% Job Duty Category Quality Improvement and Risk Management Duty/Responsibility

  • Assists the Public Health and Risk Manager 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:
    • Maintain data on occurrence reporting information
    • Develops a program to increase patient safety
    • Develops a process to assess and monitor patient 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.
  • Serves as a member of the Quality Improvement Committee and provides support to the CSU Health Network quality improvement initiatives.

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, archives policies, and ensures on-line policy information is current, organized, and accessible.
  • Educates all staff members regarding policy changes.

Percentage Of Time 15% Job Duty Category Accreditation Duty/Responsibility

  • Serves as the internal expert/authority 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 on-going 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.
  • Determines strategies for on-site surveys and serves as the organizational liaison with the accrediting organization.
  • Coordinates follow-up with the accrediting organization after completion of a survey.

Percentage Of Time 20% Job Duty Category Safety Duty/Responsibility

  • Assists the Public Health and Risk Manager 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 managment, 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 the occurrence reporting process and oversees the CSU Health Network emergency planning efforts.
  • 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.
  • Serves as a member of the CSU Health Network Infection Prevention Committee.
  • Ensures compliance with Hazardous Materials program.

Percentage Of Time 20%

Special Instructions to Applicants

Complete applications must include:

  1. A cover letter addressing Required Job Qualifications, Preferred Job Qualifications and Essential Job Duties
  2. Resume
  3. Three professional references included within your online application.

Applicants needing assistance to submit application may contact Tammy Roehrich at tammy.roehrich@colostate.edu.

References will not be contacted without prior notification of candidates.

Search Contact Tammy Roehrich, tammy.roehrich@colostate.edu

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 or expression, or pregnancy and 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/equal access/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 Executive Director of the Office of Support and Safety Assessment, 123 Student Services Building, Fort Collins, CO 80523 -2026, (970) 491-7407.

The Section 504 and ADA Coordinator is the Executive Director of Human Resources and Equal Opportunity, Office of Equal Opportunity, 101 Student Services Building, Fort Collins, CO 80523-0160, (970) 491-5836.

Background Check Policy Statement

Colorado State University (CSU) 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. The type of background check conducted varies by position and can include, but is not limited to, criminal (felony and misdemeanor) history, sex offender registry, motor vehicle history, financial history, and/or education verification. Background checks will be conducted when required by law or contract and when, in the discretion of the university, it is reasonable and prudent to do so.

Employment and Appeal Rights

If you receive notice that you have been eliminated from consideration for the position, you may protest the action by filing an appeal with the State Personnel Board/State Personnel Director within 10 days from the date you receive notice of the elimination. Also, if you wish to challenge the selection and comparative analysis process, you may file an appeal with the State Personnel Board/State Personnel Director within 10 days from the receipt of notice or knowledge of the action you are challenging.

Refer to Chapters 4 and 8 of the State Personnel Board Rules and Personnel Director’s Administrative Procedures, 4 CCR 801, for more information about the appeals process. The State Personnel Board Rules and Personnel Director’s Administrative Procedures are available at www.colorado.gov/spb.

A standard appeal form is available at: www.colorado.gov/spb. If you appeal, your appeal must be submitted in writing on the official appeal form, signed by you or your representative, and received at the following address within 10 days of your receipt of notice or knowledge of the action: Colorado State Personnel Board/State Personnel Director, Attn: Appeals Processing, 1525 Sherman Street, 4th Floor, Denver, CO 80203. Fax: 303-866-5038. Phone: 303-866-3300. The ten-day deadline and these appeal procedures also apply to all charges of discrimination.