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.

• 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.
• Performs other duties as assigned.

• 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

CHS Careers