Quality and Risk Specialist

Cibola General Hospital; Grants (NM); On-site; USD 70,000 - 90,000; Full time

Job summary

Cibola General Hospital in Grants, NM is seeking a Quality/Risk Management Coordinator to support QA, patient safety, regulatory compliance, accreditation readiness, and risk management across the organization.

The coordinator works with nursing leadership, medical staff, and operations to promote survey readiness, track quality metrics, and coordinate investigations and corrective actions.

Qualifications

• Bachelor’s degree required.
• Minimum of three (3) years of healthcare experience.
• Experience in quality improvement, accreditation, compliance, patient safety, or risk management preferred.

Responsibilities

• Coordinate hospital-wide QAPI activities and performance improvement initiatives.
• Assist with incident reporting, RCAs, and risk mitigation.
• Support regulatory & accreditation readiness for CMS, The Joint Commission, and CAH standards.
• Prepare agendas, reports, dashboards, and executive summaries for quality and safety meetings.
• Maintain confidential quality and risk management files and assist with education on patient safety.

Skills

Project coordination

Regulatory standards

Quality improvement

Data reporting

MS Office

Communication

Education

Bachelor’s degree

Tools

Healthcare reporting systems

Microsoft Office

Job description

Description

The Quality/Risk Management Coordinator supports the hospital’s quality improvement, patient safety, regulatory compliance, accreditation readiness, and risk management programs. This position serves as an operational and administrative extension of the Vice President of Regulatory Risk & Professional Practice Development and assists with day-to-day coordination of quality, patient safety, survey readiness, and regulatory activities across the organization.

Job Type

Full-time

Description

The Quality/Risk Management Coordinator supports the hospital’s quality improvement, patient safety, regulatory compliance, accreditation readiness, and risk management programs. This position serves as an operational and administrative extension of the Vice President of Regulatory Risk & Professional Practice Development and assists with day-to-day coordination of quality, patient safety, survey readiness, and regulatory activities across the organization.

The coordinator works collaboratively with nursing leadership, medical staff, department directors, and operational teams to promote continuous survey readiness, performance improvement, patient safety, and organizational compliance with CMS, Critical Access Hospital (CAH), and accreditation standards.

This role is designed to provide operational support for quality and risk initiatives while allowing executive leadership to focus on physician relations, strategic initiatives, regulatory oversight, and organizational operations.

Quality Improvement & Performance Improvement

• Coordinate and support hospital-wide Quality Assurance and Performance Improvement (QAPI) activities.
• Assist departments with performance improvement initiatives, corrective action plans, and follow-up monitoring.
• Track organizational quality metrics, dashboards, and regulatory indicators.
• Assist with collection, validation, trending, and reporting of quality and patient safety data.
• Support implementation and monitoring of process improvement initiatives.
• Maintain action plan trackers and ensure accountability for assigned deliverables.

Risk Management & Patient Safety

• Coordinate the hospital’s incident reporting and event management processes.
• Review occurrence reports and elevate high-risk concerns to leadership.
• Assist with preliminary investigations of adverse events, near misses, grievances, and patient safety concerns.
• Coordinate follow-up documentation and maintain risk management logs and tracking systems.
• Assist with Root Cause Analyses (RCA), focused reviews, and risk mitigation activities.
• Monitor trends and identify opportunities for operational and clinical risk reduction.

Regulatory & Accreditation Readiness

• Assist with ongoing readiness for CMS, The Joint Commission, Critical Access Hospital Conditions of Participation, & state regulatory requirements.
• Coordinate survey readiness activities including tracers, mock surveys, rounding, & compliance audits.
• Assist with maintaining regulatory documentation, evidence binders, & accreditation readiness materials.
• Track regulatory findings, corrective action plans, & sustainability monitoring.
• Support policy review & revision processes to ensure regulatory alignment.

Administrative & Operational Support

• Prepare agendas, reports, dashboards, committee minutes, & executive summaries for quality, safety, & regulatory meetings.
• Coordinate meeting follow-up items & maintain tracking tools for organizational initiatives.
• Assist with peer review tracking, FPPE/OPPE administrative support, & provider quality documentation.
• Maintain confidential quality & risk management files in accordance with regulatory & legal requirements.
• Support special projects & organizational initiatives assigned by executive leadership.

Education & Collaboration

• Assist with staff education related to patient safety, event reporting, regulatory compliance, & quality improvement.
• Collaborate with department leaders to improve compliance, documentation, & operational workflows.
• Promote a culture of safety, accountability, & continuous improvement across the organization.
• Serve as a resource to departments regarding quality & risk management processes.

Requirements

Required Qualifications

• Bachelor’s degree required.
• Current Registered Nurse (RN) license required.
• Minimum of three (3) years of healthcare experience required.
• Experience in quality improvement, accreditation, compliance, patient safety, or risk management preferred.
• Critical Access Hospital or rural healthcare experience preferred.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) preferred.
• Experience with CMS Conditions of Participation, The Joint Commission, or Critical Access Hospital standards preferred.
• Certification in Healthcare Quality (CPHQ), Patient Safety (CPPS), or Healthcare Risk Management (CPHRM) preferred.
• Experience with incident reporting systems, regulatory surveys, & performance improvement methodologies preferred.

Knowledge, Skills, And Abilities

• Knowledge of hospital regulatory & accreditation standards.
• Strong organizational & project coordination skills.
• Ability to manage multiple priorities & deadlines simultaneously.
• Strong analytical & critical thinking skills.
• Excellent written & verbal communication abilities.
• Ability to maintain confidentiality & exercise professional judgment.
• Proficiency with Microsoft Office applications & healthcare reporting systems.
• Ability to work collaboratively across departments & leadership levels.

Physical Requirements

• Prolonged periods of sitting, standing, & computer work.
• Ability to travel throughout hospital departments.
• Ability to occasionally lift up to 25 pounds.

Work Environment

This position operates in both clinical & administrative healthcare settings and requires interaction with leadership, providers, staff, patients, & regulatory agencies as needed. The role involves handling confidential & sensitive information and supporting time-sensitive organizational priorities.