Accreditation and Regulatory Readiness Specialist

Summary Join Carroll Hospital's Performance Improvement team as an Accreditation and Regulatory Readiness Specialist. In this role you will lead system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards, CMS Conditions of Participation (CoPs), and other state and federal regulatory agencies. Responsibilities include facilitating ongoing readiness for accreditation surveys and regulatory complaint investigations. Responsibilities Ensure continuous regulatory readiness and compliance with accreditation, certification and regulatory standards. Interpret regulatory, accreditation and disease‑specific care requirements and align them with hospital and clinic policies. Conduct patient and system tracers through direct observation to assess compliance and identify improvement opportunities. Collaborate with quality teams and organizational leaders to develop action plans and drive performance improvement initiatives. Provide regulatory readiness training and orientation for new leaders and staff, and support compliance‑related committees and workgroups. Maintain organized documentation systems, databases and information sources for accreditation, quality initiatives and regulatory reporting. Collect, analyze and report compliance and performance data to support continuous readiness and quality improvement efforts. Perform medical record audits, communicate findings, track corrective actions and ensure timely submission of required reports. Stay current on regulatory requirements, CMS, TJC, evidence‑based standards and quality metrics; assist with external surveys and reviews. Educate staff on compliance expectations, non‑compliance identification and escalation while maintaining professionalism, confidentiality and effective stakeholder communication. Qualifications 5-7 years of hospital experience required. Healthcare related license preferred. #J-18808-Ljbffr LifeBridge Health