Accreditation and Policy Management Coord

UT Southwestern Medical Center • Dallas, TX

2d

About The Position

Join our team and help launch the first state psychiatric hospital in Dallas-Fort Worth, where innovative caregivers will make a lasting impact on behavioral health in Texas.
The Texas Behavioral Health Center is a newly completed state-funded psychiatric hospital opening in Dallas’ Southwestern Medical District that is owned by the Texas Health and Human Services Commission (HHSC) and operated by UT Southwestern Medical Center.
When fully operational, the 505,000-square-foot facility will house 292 beds – 200 for adult patients and 92 for children and adolescents. As DFW’s first state-funded behavioral health hospital, it is designed to deliver state-of-the-art, patient-centered care in a modern and healing environment. The center provides comprehensive behavioral health treatment and features private patient rooms, abundant access to natural light and nature, and thoughtfully designed spaces that promote recovery. The hospital will also provide training to all behavioral health disciplines.
As employees of UT Southwestern, team members will join a world-class academic medical center committed to patient-centered care, innovation, interdisciplinary collaboration, and preparing patients for successful reintegration into their families and communities. With competitive benefits and a mission-driven culture, Texas Behavioral Health Center offers an unparalleled opportunity to make a lasting impact on mental health care in North Texas.
WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career!

Requirements

• Bachelor's Degree in healthcare administration, nursing, public health, or related field
• 3 years of experience in healthcare accreditation, regulatory affairs, or quality management, preferably in behavioral health

Nice To Haves

• Master's Degree in healthcare administration, nursing, public health, or related field
• 5 years of experience in healthcare accreditation, regulatory affairs, or quality management, preferably in behavioral health

Responsibilities

• Collaborates with clinical and administrative departments to ensure policies, procedures, and practices comply with accreditation, regulatory, ethical, and patient safety standards.
• Reviews, evaluates, and revises organizational policies and procedures to ensure compliance with CMS, TJC, and other applicable regulatory requirements, incorporating evidence-based practice.
• Interprets accreditation standards, identifies compliance gaps, and facilitates implementation of corrective action plans, monitoring tools, and sustainability measures.
• Coordinates and supports continuous survey readiness activities, including tracers, readiness rounds, self-assessments, and preparation for accreditation and certification surveys.
• Maintains and manages the electronic policy and procedure repository, providing guidance and support to departments on policy development and maintenance.
• Partners with subject matter experts to develop, document, and streamline policies, procedures, workflows, and process maps into clear, concise, and standardized formats.
• Supports regulatory submissions and follow-up activities, including FSA/PPR, Evidence of Standards Compliance (ESC), responses to complaints, and survey action plans.
• Communicates new and revised policies in a timely manner and collaborates with Education and leadership to support effective deployment and staff understanding.
• Monitors regulatory trends and evolving accreditation standards, providing education, guidance, and interpretation to leadership, committees, and staff.
• Communicates unresolved compliance issues to management and leadership, collaborates on resolution strategies, and performs additional duties as assigned.

Benefits

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100%25 coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees