Regulatory Accreditation Specialist

Tampa General Hospital•Tampa, FL

About The Position

The Regulatory Accreditation Specialist performs audit activities across the healthcare system to support the delivery of high-quality healthcare services. The role audits clinical processes and behaviors related to patient safety, regulatory compliance, and quality of care, assessing adherence to guidelines and the successful implementation of process changes. The specialist reports to Accreditation and Regulatory Management leadership and performs duties in accordance with Tampa General Hospital’s mission, vision, and values.

Requirements

Bachelor’s degree in Nursing or another related field.
At least three years of experience in a hospital or healthcare-related setting, including at least two years in quality, risk, or regulatory compliance.
Demonstrated experience with The Joint Commission (TJC) and other regulatory agencies or certification survey processes.
Experience with related tools, including computer programs such as Word and Excel.
Clinical experience sufficient to understand clinical terminology and roles and to navigate the EMR.
Knowledge of medical terminology, disease processes, and treatment modalities.
Comfort working in clinical settings as an observer of real-time clinical processes.
Proficiency in reading, analyzing, and applying data sets from platforms used by the organization.
Clear, concise written and verbal communication.
Attention to detail, organizational skills, and ability to prioritize tasks in a fast-paced environment.
Proficiency in data platforms and Microsoft Office applications.

Responsibilities

Collect relevant data by reviewing patient records, conducting interviews, and observing clinical practices in patient care areas across the system.
Perform tracers as directed by leadership to support continuous accreditation readiness.
Monitor whether implemented changes achieve intended improvements in response to action planning and formal quality improvement work.
Create and distribute collection tools with data elements that can be collated and trended.
Direct and train users on data collection tools to achieve acceptable inter-rater reliability.
Manage data collection, aggregation, and dissemination as directed by leadership.
Use auditing platforms to collect and organize findings, and standard reporting tools to ensure data is valid, informative, and meets measurement standards.
Collaborate with performance improvement, patient safety, infection prevention, and clinical teams to ensure audit tools are complete and appropriate data governance is followed.
Participate in audits and inspections conducted by regulatory bodies or accreditation agencies.
Maintain expertise in quality, safety, and regulatory indicators and specifications, understand sources of internal measurement, and implement new measurement requirements.