Clinical Compliance Nurse

Clinical Compliance Nurse

The Clinical Compliance Nurse serves as a key member of the multidisciplinary Compliance Department and is responsible for conducting focused chart reviews to assess compliance with organizational policies, regulatory requirements, accreditation standards, and clinical best practices. This position is not primarily focused on Clinical Documentation Improvement (CDI) or utilization review, but rather on identifying system-wide trends, process gaps, and opportunities for education and performance improvement.

Working collaboratively with Compliance, Quality, Risk Management, Nursing Leadership, Medical Staff, Registration, and Operations teams, the Clinical Compliance Nurse analyzes clinical records across Emergency Department, Observation, and Inpatient settings to identify underlying causes of documentation, workflow, and compliance issues. Findings are used to develop education, corrective action plans, and process improvements that strengthen clinical operations and reduce organizational risk.

ESSENTIAL RESPONSIBILITIES

• Conduct routine and targeted chart audits across Emergency Department, Observation, and Inpatient services.
• Review documentation, workflows, and clinical practices for compliance with organizational policies, regulatory requirements, and accreditation standards.
• Identify trends, patterns, and recurring compliance concerns through chart reviews and data analysis.
• Investigate underlying causes of documentation and process deficiencies and collaborate with leaders to develop sustainable solutions.
• Partner with Compliance, Quality, Risk Management, and Operations teams on system-wide improvement initiatives.
• Provide education and coaching to nursing staff, providers, admissions/registration personnel, and departmental leaders.
• Assist with regulatory survey readiness activities and corrective action plans.
• Participate in root cause analyses, focused reviews, and performance improvement projects.
• Develop audit tools, educational materials, and compliance monitoring reports.
• Monitor implementation and effectiveness of corrective actions across facilities.
• Support Quality Assessment and Performance Improvement (QAPI) initiatives.
• Maintain knowledge of CMS Conditions of Participation, state regulations, accreditation standards, and organizational policies.
• Other duties as assigned

QUALIFICATIONS

• Current Registered Nurse (RN) license.
• Bachelor's Degree in Nursing (BSN) required; Master's degree preferred.
• Minimum five (5) years of clinical nursing experience in Emergency Department, Observation, Acute Care, or Hospital Operations.
• Experience in healthcare compliance, quality, accreditation, risk management, clinical operations, or nursing leadership preferred.
• Strong understanding of hospital regulatory requirements and accreditation standards.
• Experience conducting audits, investigations, performance improvement activities, or chart reviews preferred.
• Excellent communication, presentation, and educational skills.
• Ability to analyze data, identify trends, and implement corrective actions.

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