Accreditation & Compliance Lead (Joint Commission)

Baylor Scott & White Health; Rowlett (TX); On-site; USD 85,000 - 115,000; Full time

Job summary

Baylor, Scott and White Health seeks an experienced compliance professional to support accreditation efforts and maintain survey readiness across the organization. You will interpret standards, advise leadership, coordinate Joint Commission activities, and participate in hospital-wide quality improvement initiatives while ensuring regulatory licensure compliance.

This role partners with clinical and administrative teams to develop corrective actions and prepare documentation for surveys and

Qualifications

• Bachelor's degree required.
• Minimum of 3 years of experience in accreditation/compliance.
• Knowledge of Joint Commission standards and regulatory requirements.
• Experience coordinating surveys and preparing action plans.

Responsibilities

• Coordinates Joint Commission activities to ensure facilities comply with all required standards.
• Reviews and recommends changes to policies and procedures and assesses care environment plans.
• Provides consultative help for action plan development and tracks progress with leadership.
• Prepares written responses and corrective action plans for Joint Commission recommendations.
• Delivers education on accreditation requirements and facilitates quality improvement teams.
• Prepares for accreditation surveys and handles follow-up deliverables.
• Serves as liaison during complaint investigations or licensure activities with regulatory bodies.
• Presents periodic reports on changes in accreditation standards or licensure rules.

Skills

Strategic planning

Assessment initiatives

Accreditation standards

Verbal communication

Written communication

Statistical analysis

Presentation skills

MS Office Suite

Education

Bachelor's Degree

Tools

Epic Experience

MS Office Suite

Job description

Baylor, Scott and White Health seeks an experienced compliance professional to support accreditation efforts and maintain survey readiness across the organization. You will interpret standards, advise leadership, coordinate Joint Commission activities, and participate in hospital-wide quality improvement initiatives while ensuring regulatory licensure compliance.

This role partners with clinical and administrative teams to develop corrective actions and prepare documentation for surveys and