Stroke Program Coordinator RN
Las Cruces, NM - USA
Job Summary
$20000 Sign On Bonus for eligible positions.
Why us
We know its not just about finding a job. Its about finding a place where you are respected valued and where your work is purposeful and fulfilling. A place where your talent is recognized professional development is encouraged and career advancement is possible.
Job Summary
The Accreditation Coordinator supports the facilitys ongoing readiness for accreditation and regulatory compliance by coordinating survey preparedness facilitating performance improvement initiatives and educating staff on applicable 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
- Associate Degree in Nursing Healthcare Administration Public Health or a related field required
- Bachelors 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
Knowledge Skills and Abilities
- Knowledge of accreditation and regulatory requirements applicable to hospitals and healthcare facilities.
- Strong understanding of performance improvement tools root cause analysis and process mapping.
- Effective communication and facilitation skills with the ability to work across clinical and administrative teams.
- Ability to analyze and interpret data to identify trends and inform decision-making.
- Proficiency in Google Suite or Microsoft Office and electronic quality/compliance reporting tools.
Licenses and Certifications
- CPHQ - Certified Professional in Healthcare Quality preferred or
- CHCQM - Certified Healthcare Quality Management preferred
- RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred
This position is not eligible for immigration sponsorship now or in the future Applicants must be authorized to work in the U.S. for any employer.
#INDNUR
Required Experience:
IC
About Company
For more than 40 years, CHS has been developing and operating healthcare delivery systems committed to helping people get well and live healthier.