Quality Assurance Analyst Joint Commission Tracer

Education:

• Bachelors Degree (Required)
• Masters Degree (Preferred)

Experience:

• Minimum 5 years of healthcare-related experience
• Quality Assurance or Regulatory Compliance experience required
• Knowledge of Joint Commission CMS and DOH requirements
• Experience with regulatory surveys or accreditation activities
• 3 years of Project Management experience preferred
• Strong Microsoft Office skills (Word Excel PowerPoint Outlook)
• Excellent verbal and written communication skills
• Experience managing and interpreting data
• Ability to manage multiple projects timelines and deadlines

• Support hospital-wide regulatory readiness and compliance activities.
• Conduct tracers mock surveys and focused standards assessments.
• Assess compliance with Joint Commission CMS and DOH standards.
• Identify areas of risk and assist with corrective action plans.
• Review and analyze compliance data and monitoring tools.
• Collaborate with departments and leadership to maintain accreditation readiness.
• Serve as a liaison during regulatory and accreditation surveys.
• Provide education and training on regulatory requirements.
• Participate in quality committees survey activities and process improvement initiatives.
• Maintain documentation and reports related to survey and regulatory activities.
• Perform additional duties as assigned.