Coordinator, Accreditation, Patient Safety Ambulatory (Full Time, Day)

NorthBay Health•Fairfield, CA

1d•$45 - $55•Onsite

About The Position

At Northbay Health, the Ambulatory Accreditation and Patient Safety Coordinator supports continuous regulatory readiness, licensing coordination and patient safety activities across ambulatory and outpatient settings. Working under the direction of the Accreditation, Regulatory and Licensure Manager, the Ambulatory Accreditation and Patient Safety Coordinator partners with ambulatory leaders, department managers, regulatory subject matter experts, and other stakeholders to promote compliance with applicable accreditation, regulatory, and licensing requirements. The Ambulatory Accreditation and Patient Safety Coordinator organizes and monitors ambulatory readiness activities, including tracers and audits, regulatory calendars, action plans, licensing activities, policy reviews, educational resources and evidence of sustained compliance. The position also supports onsite and offsite surveys by serving in an assigned survey or Command Center role and coordinating requested documentation and follow up activities. In collaboration with the Accredtation Program Manager, the Coordinator supports designated patient safety activities, including follow-up, data collection, trend reporting, educational publications, and implementation of risk-reduction strategies. The position contributes to NorthBay Health’s culture of safety, High Reliability Organization journey, and commitment to zero harm. The Ambulatory Accreditation and Patient Safety Coordinator works independently within the assigned scope and demonstrates initiative, sound judgement, organization, communication, and critical-thinking skills. Matters requiring regulatory interpretation, clinical judgment, legal review, or organizational decision-making are escalated to the appropriate manager or subject-matter owner.

Requirements

Baccalaureate Degree in a health science or related field or equivalent of education and experience equal to 8 years.
Minimum of four years of administrative support in healthcare experience.
Minimum of two years relevant experience in the areas of process improvement, change management, or equivalent and a solid working knowledge of improving patient safety.
Demonstrated initiative, follow through and ability to work independently.
Demonstrated effective project management skills.
Experience with accreditation, licensure and regulatory paperwork, action plans and surveys.
Microsoft Office experience
Excellent written and verbal communication and presentation skills.
Must be able to deal with job-related stress, multiple projects and deadlines.
Advanced computer skills (spreadsheets, graphs, tables and reports).

Responsibilities

Coordinates ambulatory and outpatient continuous readiness activities, including tracers, regulatory audits, readiness assessments, education, and follow-up activities.
Maintains the ambulatory accreditation, regulatory, and licensure calendar to ensure that surveys, assessments, applications, renewals, action plans, and other required activities are completed within established time frames.
Coordinates and monitors action plans resulting from Joint Commission, CMS, CDPH, internal tracers, mock surveys, and other accreditation or regulatory reviews. Tracks responsible owners, due dates, evidence of completion, and sustained compliance.
Maintains dashboards and tracking systems for ambulatory accreditation findings, regulatory requirements, licensing activities, corrective actions, and assigned patient safety measures.
Coordinates ambulatory components of Joint Commission intracycle monitoring and accreditation assessment activities, including maintenance of information in the applicable Joint Commission readiness platform.
Conducts or coordinates ambulatory tracers, rounding, and compliance audits. Communicates identified concerns and assists responsible operational leaders with documenting corrective actions and evidence of sustained compliance.
Coordinates continuous readiness activities before, during, and after accreditation and regulatory surveys, including document preparation, survey logistics, Command Center support, information requests, and post-survey follow-up.
Assists with ambulatory and outpatient licensing applications, renewals, changes, and required documentation, including applicable CDPH facility applications, CLIA certificates, and business licenses.
Assists the Pharmacy Director with preparing and submitting new and renewal Board of Pharmacy applications. Maintains the licensing tracker, monitors application and renewal deadlines, coordinates supporting documentation, and follows up on application status. The Pharmacy Director retains operational oversight, regulatory accountability, and final approval of all submissions.
Assists authorized DEA registrants and applicable operational leaders with coordinating site-specific DEA applications and renewals, monitoring expiration dates, maintaining supporting documentation, and tracking application status. The authorized registrant retains responsibility for reviewing, approving, and certifying each submission.
Maintains an accurate inventory of assigned ambulatory licenses, certificates, registrations, and permits, including renewal dates, application status, supporting documentation, and designated operational owners.
Participates in new-site activation, acquisition, relocation, change-of-ownership, and service-expansion planning to identify applicable accreditation and licensing requirements, dependencies, and timelines.
Supports the Accreditation Compliance Committee, Ambulatory Quality Committee, and other assigned committees by preparing meeting materials, maintaining records, tracking action items, and coordinating follow-up with responsible leaders.
Maintains and updates ambulatory accreditation, regulatory, and licensure resources on the organization’s internal Share Space, including regulatory updates, survey-preparation tools, audit materials, educational resources, and readiness communications.
Coordinates continuous readiness and patient safety communications, including newsletters, safety stories, regulatory updates, educational materials, and other publications that promote organizational learning.
In collaboration with the Patient Safety Program Manager, supports assigned patient safety initiatives, event follow-up, data collection, trend analysis, reporting, and implementation of risk-reduction activities.
Reviews assigned Risk Identification Reports (RIR) and coordinates follow-up with the appropriate leader. Potential high-risk, adverse, sentinel, or externally reportable events are promptly escalated to the Accreditation, Regulatory and Licensure Manager, Patient Safety Program Manager, or other designated leader.
Assists with record reviews, research, event timelines, and supporting documentation for potential adverse, sentinel, or externally reportable events under the direction of the responsible manager.
Supports gap assessments and follow-up activities associated with accredited and or Federal and State regulatory requirements, and other relevant patient safety advisories.
Supports the review of ambulatory policies for alignment with applicable accreditation, regulatory, and licensing requirements. Policy approval and operational implementation remain the responsibility of the designated policy owner and approving bodies.
Collects, analyzes, and reports data related to ambulatory accreditation, regulatory readiness, licensing, corrective actions, and assigned patient safety activities.
Participates in meetings and project teams to identify accreditation, regulatory, licensing, and patient safety considerations. Escalates questions requiring interpretation, clinical judgment, legal review, or organizational decisions to the appropriate manager or subject-matter expert.
Performs other duties consistent with the purpose and scope of the position, as assigned.

Benefits

medical, dental, and vision insurance
life, disability, and long-term care coverage
paid time off including vacation, sick leave, holidays, and bereavement
a 403(b) retirement plan with employer match
education reimbursement for eligible roles
professional development and training programs
Employee Assistance Program
wellness programs
recognition programs
shift differentials
market-based compensation review and increases subject to approval and organizational performance