Accreditation Coordinator

At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.

As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.

UC Health is committed to providing an inclusive, equitable and diverse place of employment.

The Accreditation Coordinator is responsible for leading and supporting accreditation and regulatory activities for hospital inpatient and outpatient departments (HOPDs). This role ensures compliance with regulatory and accreditation requirements (e.g., CMS, The Joint Commission, state agencies), supports education and readiness efforts, maintains data and reporting systems, and facilitates strong communication and partnerships across clinical, operational, and administrative teams.

Accreditation & Compliance Readiness:
•    Lead preparation for internal and external accreditation and regulatory surveys
•    Partner with inpatient and outpatient operators to conduct mock surveys, audits and tracers to assess compliance and readiness
•    Monitor and interpret regulatory updates, intent of standards and agency scoring; translate them into action plans and tools and partner with inpatient and outpatient operations to close identified compliance gaps
•    Collaborate with clinical and operational leaders to close identified compliance gaps

Education & Training:
•    Develop and deliver education and training materials related to standards, policies, and best practices(through regular touch bases, standing leadership meetings, and formal dedicated education venues)
•    Provides instruction to end users for the AMP (Accreditation Manager Plus) system
•    Conduct competency-building sessions for leaders and staff on regulatory requirements, policies and survey readiness to promote a culture of continuous readiness and compliance.
•    Principles of adult education and learning theories applied when developing teaching plans and when implementing the instructional process.
•    Assists in the development of content of annually required safety and regulatory information

Data Management & Reporting:
•    Manage and analyze regulatory and accreditation-related data for inpatient and outpatient departments (HOPDs) (e.g., environment of care, infection prevention, patient safety) and share with operations.
•    Develop dashboards, reports, and scorecards for leadership and operational teams.
•    Track findings, action plans, and progress toward compliance goals including report outs at key forums
•    Validate and review information posted on TJC extranet site with department Manager. 

Communication & Relationship Management:
•    Serve as a liaison between inpatient and outpatient operations and internal regulatory, legal, risk, quality teams, etc.
•    Foster strong relationships with inpatient and outpatient department leaders, surveyors, and regulatory bodies.
•    Prepare leadership briefings and updates related to accreditation performance and initiatives.
•    Timely follow-up with departments/individuals as needed 

Education and Experience Requirements: 

• Bachelor's Degree - Nursing; or other healthcare related field. Master's preferred
• Professional certification preferred (e.g., HACP, CPPS, CPHQ)
• 3 - 5 Years equivalent experience Preferred

Required Skills and Knowledge: 

• Working knowledge of The Joint Commission, CMS Conditions of Participation, and state regulations 
• Strong analytical, organizational, and project management skills.
  Excellent written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Ability to interface across large and highly matrixed organizational environments.
• Ability to impact and influence behavior and scale-up learnings. 
•  Ability to supervise data analysis, interpret results and generate insights.  
• Experience with adult education & continuous improvement principles.
• Ability to design innovative tools and dashboards to support tracking and trending of regulatory compliance.