DESCRIPTION OF POSITION

This job description is a record of the essential functions of the listed job. The job description provides the employee, CEO, Human Resources, applicants, and other agencies with a clear understanding of the job, where it fits into the organization, and the skill and work requirements in relation to other jobs. Jobs are always changing to some degree and the existence of the approved job description is not intended to limit normal change and growth. The facility will make reasonable accommodations to otherwise qualified individuals who are capable of performing the essential functions of the job with or without reasonable accommodation. 

POPULATION SERVED

The position does not involve direct patient care. Age specific experience and/or special training and/or expertise is not required to serve this population.

POSITION SUMMARY

The Compliance Coordinator provides administrative and paralegal-level support for the hospital’s risk management and legal functions. This role is responsible for organizing and maintaining legal documents, tracking litigation and claims, assisting with regulatory compliance efforts, and supporting leadership in managing risk-related activities.

The position works directly with the CEO, external legal counsel, and department leaders to ensure accurate documentation, timely follow-up, and appropriate handling of legal, regulatory, and compliance matters.

JOB PURPOSE:

The Compliance Coordinator provides administrative, legal, and compliance support for the hospital’s risk management, regulatory, and litigation-related functions. This position assists leadership and legal counsel with organizing legal documentation, tracking claims and compliance activities, supporting internal investigations, maintaining regulatory readiness, and ensuring accurate documentation and follow-up related to risk and compliance matters. The role serves as a key support position in promoting organizational compliance, risk reduction, and adherence to applicable healthcare laws, regulations, and hospital policies.

POSITION QUALIFICATIONS

The Compliance Coordinator position requires a high school diploma or equivalent. The Compliance Coordinator should possess some knowledge of California laws and medical terminology. An associate’s degree or higher, as well as legal coursework or related knowledge, is preferred. A minimum of one to two years of experience in legal assistant/paralegal work and/or healthcare administration or compliance is required. The ideal candidate will have a basic understanding of legal processes, including litigation, discovery, and filing requirements, as well as document control and record retention practices. Strong proficiency in Microsoft Office applications, including Word, Excel, and Outlook, is required. Candidates must demonstrate excellent organizational, communication, and documentation skills, along with the ability to maintain strict confidentiality.

Essential Duties & Responsibilities:  

I. Legal & Litigation Support

• Organize and maintain legal case files and documentation
• Track litigations, claims, subpoenas, and legal deadlines
• Assist with preparation of: 
• Discovery responses
• Chronologies and case summaries
• Internal investigation documentation
• Coordinate document requests between departments and legal counsel
• Maintain logs of legal activity, including claims and litigation tracking
• Coordinate scheduling of depositions, legal calls, and meetings
• File legal documents with courts and regulatory agencies as directed

II. Risk Management Support

• Maintain investigation records
• Track adverse events, complaints, and grievances
• Assist in compiling documentation for Root Cause Analyses (RCA)
• Support reporting and tracking of risk trends
• Ensure accurate and organized storage of all risk-related documentation

III. Regulatory & Compliance Support

• Assist with preparation for surveys (CDPH, CMS, Joint Commission)
• Maintain policy and compliance documentation
• Track regulatory requests and ensure timely follow-up
• Support audit preparation and documentation reviews
• Audit patient charts regularly and determine where risk may be involved
• Keep up to date knowledge of changing laws
• Assist in monitoring compliance-related activities and deadlines

IV. Administrative & Coordination Duties

• Conduct basic legal and regulatory research
• Prepare reports, correspondence, and documentation
• Organize and maintain physical and electronic filing systems
• Coordinate meetings, conference calls, and scheduling
• Communicate with external parties (attorneys, agencies, vendors)
• Provide administrative support to CEO related to legal and risk matters
• Assist with special projects as assigned

V. EXCHANGE OF IDEAS

• Ability to effectively communicate and exchange information
• Frequent interaction with: 
• CEO and leadership team
• Legal Counsel
• Department managers
• External agencies

DEMANDS AND CHARACTERISTICS OF WORK, EQUIPMENT USAGE,

 AND WORK ENVIRONMENT.

PERCENTAGE OF WORK TIME 1-33% 34-66% 67-100%

1. Standing/Walking X 
2. Sitting X
3. Twisting X 
4. Lifting/Carrying X 
5. Pushing/Pulling X 
6. Climbing (Ascending/descending) X  
7. Bending/Stooping X 
8. Using arm muscles frequently or for extended periods. X
9. Using leg muscles frequently or for extended periods. X  
10. Using back muscles frequently or for extended periods. X  

LIFTING REQUIREMENTS – Individuals in patient care positions are required to lift a patient with or without assistance.

1. 2-10 Pounds X
2. 11-20 Pounds X
3. 21-30 Pounds X  
4. 31-40 Pounds X  
5. 41-50 Pounds X  
6. 51 Pounds or More X  

WORKING ENVIRONMENT

1. Working in hot, cold, wet surroundings X  
2. Working outdoors X  
3. Working with or near chemicals X  
4. Working near radiation sources X  
5. Potential exposure to communicable diseases X  
6. Working with hazardous waste materials X  
7. Utilizing essential upgraded or adaptive equipment as industry standards require   
8. Using hand tools X  
9. Operating vehicle X  
10. Potential for cuts and bruises X  

EXCHANGE OF IDEAS

1. Ability to express or exchange ideas. X
2. Ability to understand communication of others with or without adaptive devices. X
3. Ability to perform basic math. X
4. Ability to read at an elementary level. X

WORKPLACE BEHAVIORS

I. Results Orientation – Meets current objectives and positions the organization for future growth. Completes daily tasks and assignments and processes large volumes of work associated with the operation of the department.

II. Social Sensitivity – Builds positive relationships based on respect for others. Demonstrates a helpful positive attitude. Maintains effective communication with peers, medical staff, patients, visitors, and families.

III. Quality Outcomes – Meets and exceeds expectations of internal and external customers. All organizational and departmental standards regarding quality of performance are met. Demonstrates a strong commitment to confidentiality. Participates in quality improvement programs as directed.

IV. Safe Working Environment – Demonstrates an awareness of and adherence to safety and legal requirements established at the facility with an emphasis on maintaining a safe environment for all persons working in the facility.

A. Accident/Injury Reporting – Reports any accidents, injuries and unsafe equipment and conditions to supervisor by the end of the shift and reports any pre-existing conditions as identified by the ADA.

B. Unsafe Conditions – Immediately reports, and corrects, if possible, unsafe conditions or equipment.

C. Workplace Standards – Complies with relevant regulations and standards and policies governing safe workplace environment (OSHA, Accreditation, etc.)

D. Safety Techniques – Maintains current knowledge of all aspects of the facility’s safety program by attending safety-related training as mandated upon hire, and thereafter as required by facility.

E. Modified Work – Accepts modified work assignments after receiving the physician’s release to return to work following an accident or injury.

F. Follow Prescribed/Recommended Treatment – Follows the prescribed/recommended treatment by treating physician(s) after an accident or injury.

V. Education – Participates in required inservice and educational programs on an ongoing basis.

VI. Attendance and Punctuality – Follows all facility guidelines outlining standards of attendance and punctuality. Responsible for reporting to work and completing work at assigned times.

UNIVERSAL PRECAUTIONS

Universal precautions will be observed in order to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. All blood or other potentially infectious materials will be considered infectious regardless of the status. The category shown below is designed to communicate the risk of exposure for this particular position.

? Category III

Tasks of employment involve no contact with moist body substance, non-intact skin or mucous membranes.

The employee must have the ability to perform essential functions without posing a “direct threat” in the workplace.