Accreditation Coordinator

The Accreditation Coordinator supports the facility's ongoing readiness for accreditation and regulatory compliance by coordinating survey preparedness, facilitating performance improvement initiatives, and educating staff on applicable standards. In collaboration with clinical and administrative leaders, this role monitors and promotes adherence to regulatory requirements, accreditation standards, and hospital licensure criteria, while serving as a key liaison with accrediting and regulatory agencies.

• Coordinates all accreditation and regulatory readiness activities across departments, ensuring ongoing compliance with standards from accrediting bodies such as The Joint Commission (TJC), CMS, and state agencies.
• Serves as liaison with external accrediting and regulatory agencies, supporting survey preparation, coordination, and follow-up.
• Facilitates multidisciplinary teams to address compliance gaps and implement corrective action plans.
• Conducts routine compliance rounds in clinical and non-clinical areas, identifying issues, educating staff, and escalating concerns when needed.
• Provides education and training on accreditation standards, performance improvement methodologies, and regulatory changes to hospital staff and leadership.
• Collaborates with hospital leadership and medical staff to track and trend performance indicators related to quality, safety, and accreditation.
• Assists departments in developing and evaluating policies and procedures to ensure alignment with accreditation and licensure standards.

• Associate Degree in Nursing, Healthcare Administration, Public Health, or a related field required
• Bachelor's Degree in Nursing, Healthcare Administration, Public Health, or a related field preferred
• 3-5 years of experience in accreditation, regulatory compliance, or quality improvement in a healthcare setting required
• Prior experience coordinating Joint Commission or CMS survey readiness preferred

• 401k matching
• Health insurance
• Flight privileges