Accreditation Coordinator - Quality improvement


  • This role is responsible for continual hospital-wide regulatory standards compliance and accreditation. This individual provides direction, management and supervision of DNV accreditation functions through the Regulatory Council. This individual is responsible for the development and implementation of a comprehensive hospital-wide accreditation program including, development and leadership of the Accreditation/Regulatory Council structure (including roles and responsibilities), development of measurement system for assessing level of compliance with the standards and action plans to address non compliance, and development of the regulatory / accreditation education plan for the organization. This role is liaison to the State Survey Agency, accrediting organization for the organization and medical staff and is responsible for application completion, coordination of survey activities and coordination of the development of response/action plans to the State Survey Agency, accrediting organization regarding deficiencies or nonconformities identified during survey activities. This position requires access to Protected Health Information (PHI). The information accessed is limited to the minimum necessary PHI required to perform the employee's job (i.e. for claim processing, patient admissions, etc.). PHI is accessed through various computer applications, direct contact with the patient or family members and/or contact with hospital departments such as Health Information Services, Case Management, and/or other hospital departments with whom interaction is necessary.
  • Adheres to the hospital and departmental attendance and punctuality guidelines
  • Performs all job responsibilities in alignment with the core values, mission and vision of the organization
  • Performs other duties as required and completes all job functions as per departmental policies and procedures
  • Maintains current knowledge in present areas of responsibility (i.e., self education, attends ongoing educational programs)
  • Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
  • General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels.
  • May be exposed to high noise levels and bright lights.
  • May be exposed to limited hazardous substances or body fluids, or infectious organisms.
  • May be required to change from one task to another of different nature without loss of efficiency or composure.
  • Periods of high stress and fluctuating workloads may occur.
  • Long-distance or air travel as needed - not to exceed 10% travel.


  • 4 year / Bachelor's Degree in Nursing or other healthcare field (Required)
  • 4 - 5 years Healthcare with an emphasis on quality improvement or regulatory standards and an understanding of healthcare provision (Required)
  • Demonstrated knowledge of applicable State, Federal and Third party regulations (Preferred)
  • Demonstrated knowledge of the CMS Conditions of Participation, State regulations and DNV NIAHO standards (Preferred)
  • Demonstrated knowledge of quality methodologies, information technology including data collection and analysis (Preferred)
  • Not Applicable - No Certification and Licensure Requirements Required or Preferred
  • Organizational Skills
  • Communication Skills
  • Interpersonal Skills
  • Customer Relations
  • Analytical
  • Basic Computer Skills
  • Microsoft Office Suite
  • Have near normal vision - Clarity of vision (both near and far), ability to distinguish colors
  • Ability to perform - repetitive tasks/motion
  • Standing - Occasionally within shift (1-33%)
  • Walking - Frequently within shift (34-66%)
  • Sitting - Continuously within shift (67-100%)
  • Bending/Stooping - Occasionally within shift (1-33%)
  • Pushing/Pulling - Occasionally within shift (1-33%)