North Oaks Medical Center
REGULATORY & ACCREDITATION COORDINATOR - QA/PERF IMPROVEMENT
North Oaks Medical Center, Hammond, Louisiana, United States, 70403
Status: Full Time
Shift: Primarily Monday through Friday, 8-4:30pm, Hours may vary.
Exempt: Yes
Summary:
Job Summary
The Regulatory and Accreditation Specialist is responsible for ensuring the hospital's compliance with all applicable regulatory requirements and accreditation standards. This role supports continuous readiness for surveys, facilitates performance improvement initiatives, and serves as a subject matter expert on standards from organizations such as The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and state health departments.
Other information:
Education, Licensure and/or Work Experience Requirements: • Experience Required: Minimum 3-5 years of experience in healthcare regulatory, accreditation, quality improvement, administration, or clinical practice. • Excellent communication, analytical, and problem-solving skills. Proficiency in data management systems and Microsoft Office Suite. Ability to lead cross-functional teams and manage multiple priorities. • Education Required: Bachelor's degree in public health, healthcare administration, public policy, nursing, or a related field; • Licensure/Certifications Required: N/A • Experience Preferred: Strong knowledge of healthcare laws, regulations, TJC, CMS and state health department standards. • Education Preferred: Master's degree preferred.
Responsibilities:
Essential Duties and Responsibilities:
Regulatory Compliance & Survey Readiness
- Monitor and interpret regulatory and accreditation standards, updating leadership and staff on changes.
- Lead and coordinate hospital-wide readiness activities for TJC, CMS, and other regulatory surveys.
- Conduct mock surveys, tracers, and audits to assess compliance and identify gaps.
- Maintain documentation and evidence of compliance for surveyors and inspectors.
Policy & Procedure Management
- Review and ensure alignment of hospital policies with current regulatory and accreditation requirements.
- Collaborate with departments to revise and implement policies as needed.
Education & Training
- Develop and deliver training programs on regulatory standards, survey readiness, and compliance best practices.
- Serve as a resource to staff and leadership on interpretation and application of standards.
Performance Improvement & Data Analysis
- Support quality improvement initiatives related to regulatory findings or accreditation goals.
- Analyze data from audits and surveys to identify trends and opportunities for improvement.
Communication & Collaboration
- Liaise with external regulatory bodies and accreditation organizations.
- Collaborate with clinical and operational leaders to ensure compliance across all service lines.
Non-Essential Duties and Responsibilities:
-
Assist with special projects
related to quality improvement, patient safety, or strategic initiatives as assigned by leadership.
-
Support data entry and maintenance
of accreditation-related software systems or dashboards.
-
Participate in community outreach or educational events
that promote hospital quality and safety initiatives.
-
Serve on multidisciplinary committees
as a regulatory resource, such as Environment of Care or Infection Prevention, when needed.
-
Provide backup support
for other quality department functions during staff absences or peak workload periods.
-
Help coordinate logistics for surveyor visits , including scheduling meetings, preparing materials, and escorting surveyors.
-
Contribute to internal communications , such as newsletters or intranet updates, to promote awareness of regulatory topics.
-
Assist with onboarding and orientation
of new staff regarding regulatory and accreditation expectations.
-
Maintain reference materials and resource libraries
for staff education on standards and compliance.
Other duties as assigned
Shift: Primarily Monday through Friday, 8-4:30pm, Hours may vary.
Exempt: Yes
Summary:
Job Summary
The Regulatory and Accreditation Specialist is responsible for ensuring the hospital's compliance with all applicable regulatory requirements and accreditation standards. This role supports continuous readiness for surveys, facilitates performance improvement initiatives, and serves as a subject matter expert on standards from organizations such as The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and state health departments.
Other information:
Education, Licensure and/or Work Experience Requirements: • Experience Required: Minimum 3-5 years of experience in healthcare regulatory, accreditation, quality improvement, administration, or clinical practice. • Excellent communication, analytical, and problem-solving skills. Proficiency in data management systems and Microsoft Office Suite. Ability to lead cross-functional teams and manage multiple priorities. • Education Required: Bachelor's degree in public health, healthcare administration, public policy, nursing, or a related field; • Licensure/Certifications Required: N/A • Experience Preferred: Strong knowledge of healthcare laws, regulations, TJC, CMS and state health department standards. • Education Preferred: Master's degree preferred.
Responsibilities:
Essential Duties and Responsibilities:
Regulatory Compliance & Survey Readiness
- Monitor and interpret regulatory and accreditation standards, updating leadership and staff on changes.
- Lead and coordinate hospital-wide readiness activities for TJC, CMS, and other regulatory surveys.
- Conduct mock surveys, tracers, and audits to assess compliance and identify gaps.
- Maintain documentation and evidence of compliance for surveyors and inspectors.
Policy & Procedure Management
- Review and ensure alignment of hospital policies with current regulatory and accreditation requirements.
- Collaborate with departments to revise and implement policies as needed.
Education & Training
- Develop and deliver training programs on regulatory standards, survey readiness, and compliance best practices.
- Serve as a resource to staff and leadership on interpretation and application of standards.
Performance Improvement & Data Analysis
- Support quality improvement initiatives related to regulatory findings or accreditation goals.
- Analyze data from audits and surveys to identify trends and opportunities for improvement.
Communication & Collaboration
- Liaise with external regulatory bodies and accreditation organizations.
- Collaborate with clinical and operational leaders to ensure compliance across all service lines.
Non-Essential Duties and Responsibilities:
-
Assist with special projects
related to quality improvement, patient safety, or strategic initiatives as assigned by leadership.
-
Support data entry and maintenance
of accreditation-related software systems or dashboards.
-
Participate in community outreach or educational events
that promote hospital quality and safety initiatives.
-
Serve on multidisciplinary committees
as a regulatory resource, such as Environment of Care or Infection Prevention, when needed.
-
Provide backup support
for other quality department functions during staff absences or peak workload periods.
-
Help coordinate logistics for surveyor visits , including scheduling meetings, preparing materials, and escorting surveyors.
-
Contribute to internal communications , such as newsletters or intranet updates, to promote awareness of regulatory topics.
-
Assist with onboarding and orientation
of new staff regarding regulatory and accreditation expectations.
-
Maintain reference materials and resource libraries
for staff education on standards and compliance.
Other duties as assigned