Accreditation and Policy Management Coordinator

UT Southwestern Medical Center • Dallas, TX

1d • Onsite

About The Position

This position collaborates with clinical and administrative departments to ensure policies, procedures, and practices comply with accreditation, regulatory, ethical, and patient safety standards. The role involves reviewing, evaluating, and revising organizational policies and procedures to ensure compliance with CMS, TJC, and other applicable regulatory requirements, incorporating evidence-based practice. The coordinator will interpret accreditation standards, identify compliance gaps, and facilitate the implementation of corrective action plans, monitoring tools, and sustainability measures. This role also coordinates and supports continuous survey readiness activities, maintains the electronic policy and procedure repository, and partners with subject matter experts to develop and streamline policies. Additionally, the position supports regulatory submissions, communicates new and revised policies, monitors regulatory trends, and communicates compliance issues to management.

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% 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