Accreditation Clinical Coordinator - Accreditation and Policy Management
The University of Texas Southwestern Medical Center, Dallas, TX, United States
Accreditation Clinical Coordinator - Accreditation and Policy Management (937876)
The Accreditation Clinical Coordinator is responsible for driving regulatory compliance and accreditation readiness within a hospital or clinical setting. This role requires a strong background in compliance, auditing, and clinical operations, with the ability to interpret regulatory standards and translate them into actionable policies, procedures, and best practices. The coordinator conducts and evaluates chart audits, identifies compliance gaps, and develops sustainable action plans to improve performance and maintain continuous survey readiness. Serving as a key liaison to external regulatory agencies, this individual confidently supports onsite surveys, guiding surveyors through organizational practices and ensuring alignment with established standards. The ideal candidate combines clinical expertise with analytical skills to assess data, recommend improvements, and collaborate across departments to strengthen overall compliance.
Benefits
UT Southwestern offers a competitive and comprehensive benefits package to eligible employees, including:
PPO medical plan, available day one at no cost for full‑time employee‑only coverage
Paid Time Off, available day one
Retirement Programs through the Teacher Retirement System of Texas (TRS)
Paid Parental Leave Benefit
Wellness programs
Tuition Reimbursement
Public Service Loan Forgiveness (PSLF) Qualified Employer
Qualifications
Education : Bachelor’s Degree or Master’s Degree
Experience : 5 years of experience in a hospital or clinic setting
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 review and validate clinical practice and policy.
Assist with reviewing and evaluating the policies and procedures for compliance to applicable standards and regulations.
Demonstrates ability to interpret accreditation standards, identify organizational gaps and facilitate implementation of processes to meet standards and/or close gaps, developing appropriate action plans and monitoring tools to sustain compliance.
Assists 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 assists 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.
Maintains systematic processes for self‑assessment with particular emphasis on continuous survey readiness, working 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.
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 and action plans, are appropriate and completed in a timely and thorough manner.
Coordinates 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 is a resource to assigned committees, management, and staff.
Provides ongoing education and interpretation of standards and the survey process to all levels of staff.
Assists/Facilitates regulatory readiness review activities to ensure all certifications and designation requirements are met as it applies to individual external regulatory bodies and professional associations, serving as a liaison between the program and hospital leadership.
Coordinates the clinical follow‑up to accreditation/certification surveys and applications.
Collaborates with other departments to address compliance issues and execute resolutions.
Security and EEO Statement
Security : This position is security‑sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.
EEO : UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.
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The Accreditation Clinical Coordinator is responsible for driving regulatory compliance and accreditation readiness within a hospital or clinical setting. This role requires a strong background in compliance, auditing, and clinical operations, with the ability to interpret regulatory standards and translate them into actionable policies, procedures, and best practices. The coordinator conducts and evaluates chart audits, identifies compliance gaps, and develops sustainable action plans to improve performance and maintain continuous survey readiness. Serving as a key liaison to external regulatory agencies, this individual confidently supports onsite surveys, guiding surveyors through organizational practices and ensuring alignment with established standards. The ideal candidate combines clinical expertise with analytical skills to assess data, recommend improvements, and collaborate across departments to strengthen overall compliance.
Benefits
UT Southwestern offers a competitive and comprehensive benefits package to eligible employees, including:
PPO medical plan, available day one at no cost for full‑time employee‑only coverage
Paid Time Off, available day one
Retirement Programs through the Teacher Retirement System of Texas (TRS)
Paid Parental Leave Benefit
Wellness programs
Tuition Reimbursement
Public Service Loan Forgiveness (PSLF) Qualified Employer
Qualifications
Education : Bachelor’s Degree or Master’s Degree
Experience : 5 years of experience in a hospital or clinic setting
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 review and validate clinical practice and policy.
Assist with reviewing and evaluating the policies and procedures for compliance to applicable standards and regulations.
Demonstrates ability to interpret accreditation standards, identify organizational gaps and facilitate implementation of processes to meet standards and/or close gaps, developing appropriate action plans and monitoring tools to sustain compliance.
Assists 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 assists 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.
Maintains systematic processes for self‑assessment with particular emphasis on continuous survey readiness, working 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.
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 and action plans, are appropriate and completed in a timely and thorough manner.
Coordinates 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 is a resource to assigned committees, management, and staff.
Provides ongoing education and interpretation of standards and the survey process to all levels of staff.
Assists/Facilitates regulatory readiness review activities to ensure all certifications and designation requirements are met as it applies to individual external regulatory bodies and professional associations, serving as a liaison between the program and hospital leadership.
Coordinates the clinical follow‑up to accreditation/certification surveys and applications.
Collaborates with other departments to address compliance issues and execute resolutions.
Security and EEO Statement
Security : This position is security‑sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.
EEO : UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.
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