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Employment Type:

Full time

Shift:

Day Shift

Description:

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.

Job Title: Regulatory, Accreditation Coordinator

Employment Type: Full Time

**Position Type: Exempt(** this position will require 50% at Silver Spring and 50% at Germantown).

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.

What We Offer:

Competitive salary

Benefits – Medical, Dental & Vision, PTO, Free Parking, Metro Access, Tuition Reimbursement, 403(b)

Advancement: Career growth opportunities

Minimum Licensure/Certification Required (if applicable):

Registered Nurse with current Maryland license

Minimum Knowledge, Skills, and Abilities Required:

+ 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.

**Reports to:** Manager, Accreditation and Regulatory Affairs

**Pay Range:** $33.73-$50.59

Pay is based on experience, skills and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

Holy Cross Health is an Equal Employment Opportunity (EEO) employer. Qualified applicants are considered for employment without regard to Minority/Females/disabled/Veteran (M/F/D/V) status

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About Us:

Holy Cross Health is a Catholic, not-for-profit health system that serves more than 240,000 individuals each year from Maryland's two largest counties — Montgomery and Prince George's counties. Holy Cross Health earns numerous national awards, clinical designations and accreditations across a wide range of specialties for providing innovative, high-quality health care services.

Newsweek Accolades: Voted one of America's Greatest Workplaces for Diversity and America's Greatest Workplaces for Parents and Families 2024

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran