Employment Type:

Shift:

Description:

Job Title: Regulatory Accreditation Coordinator

Employment Type: Full Time

Position Type: Exempt(this position will require 50% at Silver Spring and 50% at Germantown).

Position Summary:

• Monitor and interpret regulatory and accreditation standards from agencies such as The Joint Commission (TJC) Centers for Medicare & Medicaid Services (CMS) and state health departments in collaboration with the Manager of Accreditation and Regulatory Services.
• Coordinate hospital accreditation surveys and regulatory inspections ensuring proper documentation preparation and follow-up on any findings.
• Conduct regular audits assessments and mock surveys to identify areas of non-compliance and facilitate corrective actions.
• Serve as a resource to hospital departments providing guidance and education on regulatory and accreditation matters.
• Collaborate with interdisciplinary teams to implement quality improvement initiatives to enhance patient safety and regulatory compliance.
• Maintain current knowledge of changes in healthcare regulations and accreditation standards communicating updates to hospital leadership and staff.
• Prepare and submit required reports and documentation to regulatory bodies in a timely manner.
• Support the investigation and resolution of patient safety incidents and compliance concerns.

What We Offer:

Competitive salary
Benefits Medical Dental & Vision PTO Free Parking Metro Access Tuition Reimbursement 403(b)
Advancement: Career growth opportunities
Location: Holy Cross Health has two hospitals and four healthcare centers all a short driving distance from Washington DC and Baltimore MD

Minimum Licensure/Certification Required (if applicable):

Registered Nurse with current Maryland license

Minimum Knowledge Skills and Abilities Required:

• Bachelors Degree required; Masters Degree preferred.
• A thorough knowledge of healthcare systems with at least three (3) years of hospital experience in a clinical setting.
• Thorough knowledge of acute care regulatory/accreditation standards. Demonstrated experience in Performance Improvement Quality Risk Management and Compliance experience strongly preferred.
• Strong analytic written and verbal skills including the ability to provide educational programs to professional and management staff and physicians.
• Must have strong organizational skills.
• Must have strong interpersonal skills with team facilitation experience.
• Statistical knowledge with an ability to analyze data using statistical tools and methodology.
• Must demonstrate software proficiency using Microsoft applications to include word excel and power point.
• Must be able to read write speak and comprehend the English language and communicate verbally electronically and on hard copy.

Reports to: Manager Accreditation and Regulatory Affairs

Pay Range: $33.73-$50.59

Pay is based on experience skills and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly pay range may also vary within the stated range based on location.

Holy Cross Health is an Equal Employment Opportunity (EEO) employer. Qualified applicants are considered for employment without regard to Minority/Females/disabled/Veteran (M/F/D/V) status

About Us:

Holy Cross Health is a Catholic not-for-profit health system that serves more than 240000 individuals each year from Marylands two largest counties Montgomery and Prince Georges counties. Holy Cross Health earns numerous national awards clinical designations and accreditations across a wide range of specialties for providing innovative high-quality health care services.

Newsweek Accolades: Voted one of Americas Greatest Workplaces for Diversity and Americas Greatest Workplaces for Parents and Families 2024

Our Commitment

Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability veteran status or any other status protected by federal state or local law.