Accreditation & Quality Improvement Lead

WellSpace Health, Inc.; Sacramento (CA); On-site; USD 3,775,000 - 4,907,000; Full time

Benefits offered by this job

Competitive salary

Health benefits

Paid time off

Paid holidays

Sick leave

Flexible Spending Program

Malpractice insurance

Professional development hours

Job summary

WellSpace Health, Inc. is hiring an Accreditation Operations Coordinator to drive readiness across departments and sites. You will coordinate quality-improvement activities, compile data, and support training related to accreditation standards.

The role emphasizes teamwork, accurate reporting, and adherence to regulatory requirements. You will partner with leadership and care teams to monitor trends, prepare for surveys, and maintain documentation.

Qualifications

• Associate’s degree preferred; OR appropriate work experience necessary to perform the essential functions of the job.
• Experience in project coordination, accreditation activities, program evaluation, performance improvement, and data analysis preferred.
• Strong analytical, organizational, problem solving, and multitasking skills with ability to manage competing priorities and deadlines.
• Ability to work independently, exercise sound judgment, and maintain accuracy in a fast paced environment.
• Excellent interpersonal, customer service, verbal, written, presentation, and documentation skills.
• Strong computer proficiency, including Microsoft Office, electronic medical records, spreadsheets, presentations, and other electronic systems.
• Ability to analyze, interpret, and contextualize findings into meaningful data, reports, and actionable information
• Ability to communicate effectively and collaborate with teams from a wide variety of cultural, ethnic, and socioeconomic backgrounds.
• Results and outcomes oriented with strong emphasis on teamwork, collaboration, and High Reliability standards.
• Adherence to infection control procedures, including hand hygiene, symptom self monitoring, masking, and social distancing protocols.

Responsibilities

• Coordinate and support accreditation readiness, quality improvement, and compliance activities across departments, programs, Centers, care streams, and service locations.
• Support WellSpace Health’s Confluence Model through collaboration with Leadership, Innovation, and Accountability (LIA) leaders, operational teams, and cross functional departments.
• Conduct regular site visits, walkthroughs, tracers, readiness rounds, audits, and assessments to monitor compliance with accreditation and regulatory standards, including The Joint Commission.
• Identify areas for improvement, monitor trends and repeat findings, and support corrective actions and follow up activities.
• Track accreditation activities, readiness initiatives, performance metrics, corrective actions, timelines, and departmental deliverables to support ongoing survey readiness.
• Follow up with departments and leaders regarding overdue items, documentation gaps, corrective actions, and accreditation related requirements.
• Compile, analyze, validate, and interpret findings into meaningful reports, dashboards, and actionable information.
• Review accreditation documentation and evidence for completeness, consistency, organization, and survey readiness.
• Coordinate and maintain accreditation files, reports, trackers, meeting minutes, action items, and accreditation related software systems.
• Support accreditation surveys, mock surveys, regulatory reviews, readiness meetings, and related preparation activities.
• Assist with development of presentations, educational materials, tools, templates, and training resources related to accreditation and quality improvement.
• Support training and education activities related to accreditation standards, readiness expectations, and organizational practices.
• Promote reliable processes, aligned practices, and continuous improvement efforts that support patient safety, quality, experience, and operational excellence.
• Perform other job duties and responsibilities as assigned.

Skills

Project coordination

Accreditation activities

Data analysis

Interdepartmental collaboration

Communication skills

MS Office

Electronic medical records

Education

Associate degree preferred

Tools

Microsoft Office

Electronic medical records

Spreadsheets

Presentations

Job description

WellSpace Health, Inc. is hiring an Accreditation Operations Coordinator to drive readiness across departments and sites. You will coordinate quality-improvement activities, compile data, and support training related to accreditation standards.

The role emphasizes teamwork, accurate reporting, and adherence to regulatory requirements. You will partner with leadership and care teams to monitor trends, prepare for surveys, and maintain documentation.