Accreditation Coordinator

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

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.

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.

Preferred Experience

• Clinical Background


• Experience with MS Office Suite


• Epic Experience

Minimum Qualifications

• EDUCATION - Bachelor's Degree


• EXPERIENCE - 3 Years of Experience