About The Position

This position provides direct oversight of clinical regulatory and accreditation activities at Texas Health Harris Methodist Hospital Fort Worth (THFW) to ensure ongoing compliance, accreditation readiness, and harm reduction. The role focuses on supporting THFW through evidence-based, high-reliability, and sustainable strategies, including routine hospital site visits, tracer validation, and mock survey activities. This is a clinically licensed position responsible for observing patient care, reviewing medical records, and assessing clinical documentation and practices to identify regulatory gaps, mitigate risk, and support continuous readiness at the entity level.

Requirements

  • Bachelor’s degree in healthcare with 3 Years of Experience Required
  • 5 Years of Experience in a Hospital Setting/healthcare environment Required
  • RN – Registered Nurse Upon Hire Required Or Other Clinical Licensure Upon Hire Required
  • Knowledge of performance improvement techniques, i.e. Lean, Six Sigma, PDSA and Reliability theory.
  • Excellent verbal and written communication, negotiation, and collaboration skills
  • Ability to collect, analyze, and organize data
  • Team facilitation skills
  • Knowledge of regulatory and accreditation requirements
  • Ability to educate and motivate others
  • Ability to use Microsoft office applications.

Nice To Haves

  • Master’s degree in healthcare/business with 3 Years of Experience Preferred
  • 3 Years of Regulatory compliance and accreditation or quality improvement Preferred
  • CPHQ - Certified Professional in Healthcare Quality within 3 Years of Hire Required Or CPPS - Certified Professional in Patient Safety within 3 Years of Hire Required

Responsibilities

  • Regulatory and Accreditation
  • Performance and Process Improvement
  • Data and Analytics
  • Patient Safety

Benefits

  • 401k
  • PTO
  • medical
  • dental
  • Paid Parental Leave
  • flex spending
  • tuition reimbursement
  • Student Loan Repayment Program
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