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Accreditation Clinical Coordinator

Job Number: 65950
Categories: Professional & Executive
Location: 5323 Harry Hines Blvd, Dallas, TX
Department: 844065 - Accreditation & Patient Safety
Full/Part Time/PRN: Day Job
Regular/Temporary: Regular


This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information


Salary Negotiable

Experience and Education

Clinical degree and accompanying license required. Five (5) years experience in a clinical setting, hospital-based preferred. Clinical degree/license options include: Nursing, Laboratory Services, Pharmacy, Radiology Preferred.
Must be able to read, write and communicate in English. Strong knowledge of Joint Commission requirements Computer skills including working knowledge of EPIC and MS Excel Strong communication skills

Job Duties

  • Works in collaboration with all disciplines to ensure policies, procedures, and practices are compliant with regulatory standards.
  • Current working knowledge of ethical, regulatory and accreditation requirements and ability to interpret into sound clinical practice and policy.
  • Works in collaboration with all disciplines to ensure policies, procedures, and practices are compliant with TJC and CMS regulatory standards.
  • Assist with coordinating, developing, evaluating, reviewing, revising, and evaluating the policies and procedures with research of evidence based practice while integrating 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 and/or facilitates 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. Coordinate communication with all department, coordinate work plans related to the EMR, for accreditation and certification.
  • 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, Measures of Success (MOS) 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 Safety as well as leadership as appropriate for follow-up and action plan.
  • Assist in maintaining the calendar of all pending Hospital accreditation and certification activities.
  • 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 oversight of ongoing education and interpretation of standards and the survey process to all levels of staff.
  • Be the liaison between the program and hospital leadership; channel of communication
  • Assist in planning the survey readiness rounds and in communicating the results.
  • Collaborates with Quality Coordinators and Project Managers on patient safety and quality initiatives
  • Coordinate the clinical follow up to accreditation/certification surveys and applications.
  • Collaborates with other departments to address compliance issues and execute resolution

**Other Duties: Performs other duties as assigned.

UTSouthwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. In accordance with federal and state law, the University prohibits unlawful discrimination, including harassment, on the basis of: race; color; religion; national origin; sex; including sexual harassment; age; disability; genetic information; citizenship status; and protected veteran status. In addition, it is UTSouthwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.

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