Accreditation Coordinator

Job Description

Job Description

Position Summary

The Accreditation Coordinator supports agency-wide accreditation, regulatory compliance, audit readiness, and continuous quality improvement activities. The position works with program leadership and administrative departments to maintain ongoing compliance with applicable accreditation standards, contractual requirements, licensing regulations, and agency policies. Primary areas of focus include CARF, American Correctional Association (ACA), Prison Rape Elimination Act (PREA) audit readiness, and other standards applicable to the agency's social service, housing, reentry, behavioral health, and community-based programs.

Essential Duties and Responsibilities

Accreditation Management

· Coordinate preparation and ongoing readiness for CARF and ACA accreditation surveys, renewals, and follow-up requirements.

· Maintain accreditation calendars, standards manuals, evidence files, renewal deadlines, and required submissions.

· Assist program leadership in interpreting accreditation standards and translating requirements into operational practices.

· Coordinate site visits, record reviews, staff interviews, facility inspections, and other accreditation activities.

· Maintain organized documentation demonstrating compliance with individual accreditation standards.

PREA Audit Readiness

· Support applicable programs in maintaining readiness for PREA audits and monitoring activities.

· Coordinate collection and organization of PREA-related policies, training records, screening documentation, client education materials, reporting records, and other required evidence.

· Track PREA audit findings and corrective actions and assist responsible managers with timely resolution.

· Work with designated PREA compliance personnel and program leadership to address identified gaps.

Internal Monitoring and Corrective Action

· Conduct scheduled internal reviews, mock surveys, and documentation checks using applicable accreditation and regulatory standards.

· Identify deficiencies, prepare concise written findings, and communicate required corrective actions to program leadership.

· Maintain a centralized corrective-action tracker with responsible parties, deadlines, status, and evidence of completion.

· Follow up on open findings and escalate overdue or significant compliance concerns to the Director of Quality Assurance.

Policy, Training and Technical Assistance

· Assist with reviewing and revising policies and procedures to align with accreditation and regulatory requirements.

· Develop practical accreditation-readiness tools, checklists, guidance documents, and training materials.

· Provide technical assistance to program directors, managers, supervisors, and staff regarding accreditation expectations.

· Monitor changes in accreditation standards and communicate relevant updates to affected departments.

Continuous Quality Improvement and Reporting

· Participate in agency Continuous Quality Improvement (CQI) activities and identify trends across internal and external reviews.

· Prepare accreditation status updates and compliance reports for Quality Assurance leadership.

· Maintain survey reports, accreditation decisions, corrective-action plans, certificates, correspondence, and supporting evidence.

· Support analysis of incidents, complaints, client satisfaction, program outcomes, and other quality indicators when relevant to accreditation requirements.

Key Compliance Areas

· CARF accreditation standards

· American Correctional Association (ACA) accreditation standards

· Prison Rape Elimination Act (PREA) standards and audit requirements

· New Jersey licensing and regulatory requirements applicable to agency programs

· Government contract and grant compliance requirements

· HIPAA, confidentiality, health and safety, incident reporting, staff training, and credentialing requirements

· Continuous Quality Improvement (CQI) standards and practices

Minimum Qualifications

· Bachelor's degree in human services, Social Work, Criminal Justice, Public Administration, Healthcare Administration, Business Administration, Quality Management, or a related field.

· Two to three years of experience in quality assurance, compliance, accreditation, program operations, social services, behavioral health, corrections/reentry, housing, or a related field preferred.

· Experience with CARF, ACA, PREA, licensing, government monitoring, or comparable compliance frameworks preferred.

· Experience organizing audit documentation, conducting file reviews, or tracking corrective actions strongly preferred.

Knowledge, Skills and Abilities

· Strong organizational skills and exceptional attention to detail.

· Ability to interpret standards, policies, contracts, and regulatory requirements.

· Strong written communication, documentation, and report-writing skills.

· Ability to manage multiple deadlines and maintain accurate compliance tracking systems.

· Ability to work collaboratively with program leadership while objectively identifying compliance deficiencies.

· Proficiency with Microsoft Office and electronic document-management or compliance-tracking systems.

· Ability to travel among agency program locations in Camden County and other service areas as needed.

Performance Expectations

· Accreditation and audit deadlines are consistently met.

· Programs maintain organized and current evidence of compliance.

· Corrective actions are tracked and closed within established timeframes.

· Repeat findings are reduced through effective follow-up and technical assistance.

· Internal reviews and mock surveys are completed according to the annual monitoring schedule.

· Agency programs demonstrate continuous readiness for CARF, ACA, PREA, licensing, and other external reviews.

Other Duties

This job description describes the primary duties of the position and is not intended to be an exhaustive list. Additional responsibilities may be assigned based on organizational needs, contractual requirements, and changes in accreditation or regulatory standards.