Accreditation Coordinator

Join to apply for the Accreditation Coordinator role at Santa Rosa Medical Center

Job Summary

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.

Essential Functions

• 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.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

Knowledge, Skills And Abilities

Licenses and Certifications

Seniority level

Employment type

Job function

Industries

J-18808-Ljbffr