Clinical/Regulatory Accreditation Coordinator

Job Summary

The Clinical Accreditation Coordinator is a highly collaborative role responsible for promoting a culture of continuous survey readiness, quality, and patient safety throughout Baylor Scott & White Health. As an internal consultant and trusted resource, this position partners with clinical leaders and interdisciplinary teams to prepare for accreditation surveys, interpret standards, evaluate clinical processes, and implement best practices that support exceptional patient care.

This role is ideal for a healthcare professional with a clinical background—such as an RN, Respiratory Therapist, Pharmacy Technician, Physical Therapist, or Health Information Management professional—who enjoys educating others, solving complex problems, leading improvement initiatives, and influencing positive change across the organization.

The ideal candidate has a strong clinical or healthcare operations background and is passionate about educating others, building collaborative relationships, and driving continuous improvement through accreditation and quality initiatives. Experience with Joint Commission standards, healthcare survey readiness, clinical documentation, and performance improvement is highly valued.

Essential Functions

• Lead and coordinate accreditation and continuous survey readiness activities across the hospital, ensuring alignment with Joint Commission, CMS Conditions of Participation (CoPs), Texas Department of State Health Services (TDSHS), and other regulatory standards.
• Partner with clinical leaders, physicians, nursing, ancillary departments, and operational teams to evaluate current practices, identify opportunities for improvement, and promote ongoing accreditation readiness.
• Conduct mock surveys, tracers, documentation reviews, and departmental assessments to evaluate readiness and support continuous quality improvement.
• Review organizational policies, procedures, and clinical processes to ensure they reflect current accreditation standards, regulatory requirements, and evidence-based practices.
• Collaborate with department leaders to develop, implement, and monitor action plans that address survey findings and strengthen organizational performance.
• Prepare written responses, documentation, and corrective action plans related to accreditation surveys, regulatory reviews, and identified opportunities for improvement.
• Develop and deliver education, training, and consultation to leaders and staff regarding accreditation standards, survey expectations, documentation, and best practices.
• Coordinate all aspects of accreditation surveys, including planning, logistics, documentation, leadership preparation, survey support, and post-survey follow-up activities.
• Serve as the primary liaison with regulatory agencies, including the Texas Department of State Health Services (TDSHS), during complaint investigations, Medicare validation surveys, licensure reviews, and other regulatory visits.
• Monitor changes to accreditation standards, CMS Conditions of Participation, state regulations, and industry best practices, communicating updates and recommendations to hospital leadership.
• Prepare and present reports, survey readiness updates, compliance metrics, and improvement initiatives to executive leadership, medical staff committees, and governing boards.
• Foster a culture of continuous improvement by building collaborative relationships and supporting organization-wide quality, patient safety, and operational excellence initiatives.

Key Success Factors

• Strong knowledge of Joint Commission, CMS Conditions of Participation (CoPs), TDSHS, and healthcare accreditation standards.
• Clinical experience with an understanding of hospital operations, patient care workflows, and healthcare documentation.
• Experience interpreting accreditation standards and applying them within clinical practice.
• Ability to educate, coach, and influence interdisciplinary teams at all organizational levels.
• Excellent relationship-building, communication, and presentation skills.
• Strong analytical, critical thinking, and problem-solving abilities.
• Experience conducting tracers, mock surveys, audits, or process improvement initiatives.
• Ability to identify operational gaps and develop practical, sustainable improvement strategies.
• Strong organizational and project management skills with the ability to manage multiple priorities.
• Proficiency with Microsoft Office and healthcare documentation systems.
• Ability to analyze data, prepare reports, and communicate findings to senior leadership.
• Commitment to fostering a culture of patient safety, quality, and continuous improvement.

Preferred Experience

• Clinical background such as Registered Nurse (RN), Respiratory Therapist (RRT), Pharmacy Technician, Physical Therapist (PT), Health Information Management (HIM), Medical Records, or another licensed healthcare discipline.
• Experience participating in Joint Commission or CMS surveys.
• Hospital accreditation, quality improvement, patient safety, or clinical operations experience.
• Experience reviewing clinical documentation and medical records.
• Experience leading interdisciplinary projects and educating clinical teams.

About Us

Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.

Our Core Values are:

• We serve faithfully by doing what's right with a joyful heart.
• We never settle by constantly striving for better.
• We are in it together by supporting one another and those we serve.
• We make an impact by taking initiative and delivering exceptional experience.

Benefits

Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level.

Belonging Statement

We believe that all people should feel welcomed, valued and supported.

QUALIFICATIONS

• EDUCATION - Bachelor's Degree
• EXPERIENCE - 3 Years of Experience