Accreditation Coordinator

Baylor Scott & White Health; Round Rock (TX); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Health benefits

401(k) match

Tuition Reimbursement

PTO accrual Day 1

Job summary

Baylor Scott & White Health in Round Rock, TX seeks a healthcare compliance professional to manage accreditation programs and readiness. You will serve as an internal advisor interpreting standards and coordinating survey activities with hospital leadership.

The role requires 3+ years in healthcare compliance, a Bachelor's degree, and strong communication. You will drive continuous improvement and ensure licensure status across facilities.

Qualifications

• Bachelor's Degree required.
• Minimum 3 years in healthcare compliance or accreditation.
• Strong communication and project management skills.

Responsibilities

• Coordinate Joint Commission activities to ensure facilities comply with all required standards.
• Review and recommend changes to policies and procedures to improve health care quality and safety.
• Provide education and training on accreditation requirements and serve as an internal consultant for quality improvement.
• Prepare responses and corrective action plans for Joint Commission recommendations.
• Coordinate preparation for accreditation surveys and liaise with state health services during investigations.

Job description

About Us

Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.

Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.

Our Core Values Are

• We serve faithfully by doing what's right with a joyful heart.
• We never settle by constantly striving for better.
• We are in it together by supporting one another and those we serve.
• We make an impact by taking initiative and delivering exceptional experience.

Benefits

Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level.

Job Summary

Provides compliance for Baylor, Scott and White Health accreditation efforts. Reviews include facilitation of continuous survey readiness. Serves as an internal consultant for interpreting standards and assessing functional compliance. Participates in survey-related activities. Supports and sustains hospital-wide continuous improvement efforts.

Essential Functions Of The Role

• Coordinates Joint Commission activities to ensure facilities comply with all required standards. Develops a consistent plan for continuous compliance with accreditation standards.
• Reviews and recommends changes, additions, or deletions of policies and procedures. Evaluates health care improvement, patient safety, and information management plans. Assesses environment of care management and other organization plans.
• Provides consultative help for action plan development. Tracks progress and coordinates activities to assess compliance with accreditation standards. Identifies gaps and opportunities for improvement. Reports compliance status to senior leadership.
• Prepares written responses and development of corrective action plans regarding Joint Commission recommendations.
• Provides education and training on accreditation requirements and serves as an internal consultant facilitating quality improvement teams.
• Coordinates preparation for and execution of accreditation surveys including follow-up and ongoing deliverables.
• Serves as facility liaison to surveyors from the Texas Department of State Health Services (TDSHS) during complaint investigations or Medicare surveys. Serves as facility coordination point for all hospital licensure requirements and activities set by TDSHS.
• Presents periodic reports to senior leadership, medical staff departments, and the board of trustees about changes in accreditation standards, COP, or licensure rules.

Key Success Factors

• Knowledge of strategic planning, assessment initiatives, and accreditation standards.
• Verbal and written communication skills.
• Statistical and presentation skills.
• Skill in the use of computers and related software applications.
• Ability to assess compliance with accreditation standards and develop corrective action plans.
• Ability to work effectively with a wide range of constituencies.
• Ability to collect and organize data.
• Ability to prepare accurate reports on program status and progress.

Belonging Statement

We believe that all people should feel welcomed, valued and supported.

Qualifications

• EDUCATION - Bachelor's Degree
• EXPERIENCE - 3 Years of Experience