Accreditation Compliance Specialist

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care.   

It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community.

Benefits Eligible

Full-Time Benefit Eligible

Work Shift

Day - 8 Hour or less Shift (United States of America)

Department

8757 Organizational Accreditation

The Accreditation Compliance Specialist supports organizational readiness and compliance with regulatory and accreditation standards, including The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and the California Department of Public Health (CDPH). This role facilitates continuous survey preparedness, conducts compliance monitoring, maintains accurate and up-to-date documentation, and assists with staff education. The specialist collaborates across departments to promote a culture of safety, accountability, and sustained regulatory excellence.

QUALIFICATIONS

License /Certification
Preferred: Certification in Healthcare Accreditation (HACP)
Education
Required: Bachelor’s degree in Healthcare Administration, Nursing, or a related field
 

Experience

Required: Minimum of two years of experience in regulatory compliance, accreditation, or healthcare quality.

Preferred: Clinical experience

JOB RESPONSIBILITIES

Essential

Supports survey readiness activities by organizing documentation, coordinating mock surveys, and tracking preparedness metrics.

Assists with logistics and operations during regulatory surveys (e.g., TJC, CMS, CDPH), including Command Center support.

Conducts basic compliance spot checks and participates in tracer rounds to identify documentation and process gaps.

Tracks and follows up on audit findings, action items, and timelines to support ongoing readiness initiatives.

Maintains organized regulatory files and evidence binders, including audit tools, policies, and compliance documentation.

Utilizes accreditation audit software to document tracer findings, manage corrective actions, and generate compliance reports.

Compiles data and assists in the development of regulatory reports, dashboards, and Plan of Correction (POC) materials.

Provides administrative and editorial support for document reviews, updates, and cross-department communications.

Assists in focused standards reviews, tracks associated corrective actions and documents updates.

Coordinates logistics for training sessions, including scheduling, material preparation, and attendee tracking.

Supports department-led education efforts to increase staff awareness of regulatory and accreditation requirements.

Manages scheduling and supports logistics for regulatory meetings, including agendas, minutes, and action item follow-up.

Assists in coordinating project timelines and deliverables for accreditation and compliance initiatives.

Performs other duties as assigned.
Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area.

Pay Range

$30.76 -$46.14

If you want to use your talents alongside people who face each day with courage and purpose, in an environment that empowers you to do your absolute best, this is where you belong.