Compliance Coordinator

Role Overview

• Maintain ongoing compliance with Article 28 requirements, including staff credentialing, licensure, mandatory trainings, and documentation
• Conduct routine audits of personnel files to ensure accuracy, completeness, and adherence to regulatory standards
• Support preparation for surveys, inspections, and audits by regulatory bodies (e.g., DOH, JCAHO, CMS, ACR)
• Track and communicate upcoming expirations of staff licenses, certifications, and required training modules
• Assist in the development, implementation, and maintenance of compliance-related policies and procedures
• Create, update, and securely maintain Article 28 personnel files in accordance with hospital policies and regulatory requirements
• Ensure timely onboarding compliance, including verification of credentials, background checks, health clearances, and required orientations
• Maintain accurate digital and physical filing systems to support quick retrieval during audits or inspections
• Coordinate completion of annual competencies and training requirements for all Radiology staff
• Assist leadership with compliance dashboards, reporting, and documentation related to quality improvement initiatives
• Participate in internal audits, mock surveys, and performance improvement projects
• Collaborate with HR, Radiology Leadership, and Compliance departments to resolve discrepancies or compliance gaps
• Support incident reporting follow-up, corrective action tracking, and other administrative tasks as assigned
• Progvide timely communication to staff regarding policy updates, new regulatory requirements, or training deadlines
• Assist in maintaining employee electronic files ina accordance with institutional policies and ensure compliance with Department of Health (DOH) standards and regulatory requirements
• Assist in maintaining database and track expiration dates for all relevant regulatory certifiations including but not limited to, operating licenses, laboratory licenses, ACR renewal, Image Gently, Image Wisely among others
• Compile, track, and send all compliance related items to relevant stakeholders as needed; including but not limited to, annual DOH Flu Compliance Submission, BLS, WHS, and Vaccine Compliance
• Follow up on all requests for employee or faculty training and ensure deliverables are complete
• Proactively monitor CDNYPI compliance with Article 28 guidelines
• Work closely with Operations and Project Management team to ensure that all databases are kept up to date; interact with other stakeholders as needed

Requirements

• Bachelors degree required
• A minimum of 1 year of related experience in healthcare compliance, credentialing, radiology operations, or hospital administration required
• Proficiency in Smartsheet and/or hospital credentialing/compliance software
• Previous experience working in a hospital or ambulatory care setting
• Familiarity with DOH regulations, JCAHO standards, and healthcare licensing requirements
• Must demonstrate strong organizational and problem-solving skills
• Ability to perform across multi-disciplinary and/or specialties while maintaining high productivity and a professional and service-oriented demeanor
• Ability to work with a variety of individuals and groups in a constructive and respectful manner while appreciating the unique contributions of an inclusive workforce that brings together the talents of people across multiple identities
• Strong commitment to fostering diversity and equity
• Must have excellent communication skills, interpersonal skills, and a strong ability to deescalate stressful situations
• Must be an engaged team member, demonstrating collaboration, inclusion, reliability, punctuality, and adaptability to new and changing situations
• Basic proficiency in computer skills including, but not limited to, Electronic Health Systems, Microsoft Excel, Microsoft Word, email systems, etc.
• Must be a motivated individual with a positive mindset and exceptional work ethic
• Knowledge of Article 28 regulations or willingness to learn quickly preferred.

Benefits

• Healthcare and various other benefits including Paid Time off