Regulatory/Accreditation Nurse Coordinator

Trinity Health•Silver Spring, MD

4d•$34 - $51

About The Position

The Regulatory and Accreditation Coordinator is responsible for ensuring the hospital remains compliant with all regulatory standards, accreditation requirements, and state and federal laws. This individual collaborates with hospital leadership and staff to maintain survey readiness and promote a culture of continuous regulatory compliance and quality improvement. (RN or LPN) Position Summary: Monitor and interpret regulatory and accreditation standards from agencies such as The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and state health departments in collaboration with the Manager of Accreditation and Regulatory Services. Coordinate hospital accreditation surveys and regulatory inspections, ensuring proper documentation, preparation, and follow-up on any findings. Conduct regular audits, assessments, and mock surveys to identify areas of non-compliance and facilitate corrective actions. Serve as a resource to hospital departments, providing guidance and education on regulatory and accreditation matters. Collaborate with interdisciplinary teams to implement quality improvement initiatives to enhance patient safety and regulatory compliance. Maintain current knowledge of changes in healthcare regulations and accreditation standards, communicating updates to hospital leadership and staff. Prepare and submit required reports and documentation to regulatory bodies in a timely manner. Support the investigation and resolution of patient safety incidents and compliance concerns.

Requirements

Registered Nurse with current Maryland license
Bachelor’s Degree required; Master’s Degree preferred.
A thorough knowledge of healthcare systems, with at least three (3) years of hospital experience in a clinical setting.
Thorough knowledge of acute care regulatory/accreditation standards.
Demonstrated experience in Performance Improvement, Quality, Risk Management and Compliance experience strongly preferred.
Strong analytic, written and verbal skills, including the ability to provide educational programs to professional and management staff and physicians.
Must have strong organizational skills.
Must have strong interpersonal skills with team facilitation experience.
Statistical knowledge with an ability to analyze data using statistical tools and methodology.
Must demonstrate software proficiency using Microsoft applications to include word, excel, and power point.
Must be able to read, write, speak and comprehend the English language and communicate verbally, electronically and on hard copy.

Nice To Haves

Master’s Degree preferred.
Demonstrated experience in Performance Improvement, Quality, Risk Management and Compliance experience strongly preferred.

Responsibilities

Monitor and interpret regulatory and accreditation standards from agencies such as The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and state health departments in collaboration with the Manager of Accreditation and Regulatory Services.
Coordinate hospital accreditation surveys and regulatory inspections, ensuring proper documentation, preparation, and follow-up on any findings.
Conduct regular audits, assessments, and mock surveys to identify areas of non-compliance and facilitate corrective actions.
Serve as a resource to hospital departments, providing guidance and education on regulatory and accreditation matters.
Collaborate with interdisciplinary teams to implement quality improvement initiatives to enhance patient safety and regulatory compliance.
Maintain current knowledge of changes in healthcare regulations and accreditation standards, communicating updates to hospital leadership and staff.
Prepare and submit required reports and documentation to regulatory bodies in a timely manner.
Support the investigation and resolution of patient safety incidents and compliance concerns.