Accreditation Clinical Coordinator - Accreditation and Policy Management

UT Southwestern Medical Center • Dallas, TX

18h • Onsite

About The Position

The Accreditation Clinical Coordinator is responsible for driving regulatory compliance and accreditation readiness within a hospital or clinical setting. This role requires a strong background in compliance, auditing, and clinical operations, with the ability to interpret regulatory standards and translate them into actionable policies, procedures, and best practices. The coordinator conducts and evaluates chart audits, identifies compliance gaps, and develops sustainable action plans to improve performance and maintain continuous survey readiness. Serving as a key liaison to external regulatory agencies, this individual confidently supports onsite surveys, guiding surveyors through organizational practices and ensuring alignment with established standards. The ideal candidate combines clinical expertise with analytical skills to assess data, recommend improvements, and collaborate across departments to strengthen overall compliance.

Requirements

• Bachelor's Degree or Master's Degree
• 5 years Experience in hospital or clinic setting
• Strong background in compliance, auditing, and clinical operations
• Ability to interpret regulatory standards and translate them into actionable policies, procedures, and best practices
• Ability to conduct and evaluate chart audits
• Ability to identify compliance gaps and develop sustainable action plans
• Ability to serve as a key liaison to external regulatory agencies and support onsite surveys
• Clinical expertise
• Analytical skills to assess data and recommend improvements
• Ability to collaborate across departments
• Current working knowledge of ethical, regulatory and accreditation requirements
• Ability to review and validate clinical practice and policy
• Ability to interpret accreditation standards, identify organizational gaps and facilitate implementation of processes
• Interpersonal skills to collaborate and participate with staff, administrators and various committees

Responsibilities

• Works in collaboration with all disciplines to ensure policies, procedures, and practices are compliant with regulatory standards.
• Assist with reviewing and evaluating the policies and procedures for compliance to applicable standards and regulations.
• Demonstrates ability to interpret accreditation standards, identify organizational gaps and able to facilitate implementation of processes to meet standards and/or close gaps.
• Develop appropriate action plan and monitoring tools to sustain compliance.
• Assists regulatory readiness review activities to ensure all accreditation requirements are met at locations assigned.
• Leads tracer activities among staff to ensure continuous patient readiness and assist with preparation for survey site visits with hospital specific administration staff.
• Interpersonal skills to collaborate and participate with staff, administrators and various committees to ensure and provide regulatory support and compliance.
• Maintains systematic processes for self-assessment with particular emphasis on continuous survey readiness.
• Works collaboratively with all departments and Functional Chapter Leaders in developing, communicating, and implementing effective strategies for assessment, data collection and analysis, and distribution of findings and recommendations to the appropriate individuals, committees, and departments.
• Meets regularly with appropriate teams to provide support, assess compliance, review findings, and provide guidance for improvement as needed in order to maintain continual survey readiness.
• Works in collaboration with all departments to ensure that all required regulatory submissions and follow-up, including the annual FSA/PPR, Evidence of Standards Compliance (ESC), response to TJC or CMS complaint investigations and action plans are appropriate and completed in a timely and thorough manner.
• Communicates unresolved variances or areas of continued non- compliance with Manager and/or Director of Accreditation and Policy Management as well as leadership as appropriate for follow-up and action plan.
• Coordinate the communication with respect to anticipation of future trends and changing CMS and TJC standards to advise the organization in order to allow adequate time for appropriate response.
• Assists and be a resource to assigned committees, management, and staff.
• Provides ongoing education and interpretation of standards and the survey process to all levels of staff.
• Assist/Facilitates regulatory readiness review activities to ensure all certifications and designation requirements are met as it applies to individual external regulatory bodies, professional associations.
• Be a liaison between the program and hospital leadership; channel of communication.
• Assist in planning the survey readiness rounds and in communicating the results.
• Coordinate the clinical follow up to accreditation/certification surveys and applications.
• Collaborates with other departments to address compliance issues and execute resolution.

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: Senior
• Number of Employees: 5,001-10,000 employees