Accreditation Associate

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Job Summary:

The position will be part of UNC Health's Unified Quality division and will support one or more UNC Health hospitals and clinics. Prepare hospital leaders and teammates for surveys and the accreditation process through mock surveys, focused tracers, articles, computerized learning modules, newsletters, presentations, accreditation websites, and consultations with various departments. This role also includes patient safety project coordination, data tracking and analysis, and leading patient safety initiatives.

Description of Job Responsibilities:

1. Facilitate the interpretation of Centers for Medicare & Medicaid Services (CMS) regulations, DNV standards, and other applicable regulatory agency requirements (hereafter referred to as "standards and regulations") for the organization's leadership team.
2. Ensure organizational readiness and ongoing compliance with standards and regulations across the organization.
3. Report on the status of hospital-wide compliance with standards and regulations to organizational leaders.
4. Develop and provide educational training and support to organizational teammates.
5. Develop and track patient safety event data and create presentations to communicate findings and trends.
6. Coordinate various patient safety initiatives, including but not limited to the Safety Culture Survey, Patient Safety Awareness Week, and the Patient Safety Structural Measure. Create and assist with action plans based on survey results and identified improvement opportunities.
7. Manage CMS, Division of Health Service Regulation (DHSR), and/or DNV surveys effectively. Prepare and coordinate written survey responses as needed.
8. Participate in Patient Safety Team activities, including Learning From Defects (LFDs) reviews and Root Cause Analyses (RCAs) of patient safety, sentinel, and never events. Create and assist with action plans to prevent recurrence.
9. Maintain extensive knowledge of current accreditation, certification, and licensure requirements and standards; exercise independent judgment and decision-making; and apply data collection, validation, and analysis techniques, quality improvement concepts and tools, risk management principles, operational policies, and patient safety and care standards.

Other Information

Education Requirements:

• Bachelor's degree in an appropriate discipline or equivalent and meets professional experience requirements.
• Associate's degree in an appropriate discipline or equivalent and meets professional experience requirements.

Professional Experience Requirements:

• With a Bachelor's degree, requires two (2) years of experience in administration, project coordination, or patient care in a hospital setting.
• With an Associate's degree, requires four (4) years of experience in administration, project coordination, or patient care in a hospital setting.

Knowledge, Skills, and Abilities Requirements:

• Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.
• Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
• Ability to effectively present information to top management, public groups, and/or boards of directors.
• Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions.

Job Details

Legal Employer: NCHEALTH

Entity: UNC Rockingham Health Care

Organization Unit: Unified Quality

Work Type: Full Time

Standard Hours Per Week: 40.00

Salary Range: $28.87 - $41.50 per hour (Hiring Range)

Pay offers are determined by experience and internal equity

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: US:NC:Eden

Exempt From Overtime: Exempt: Yes

This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position.


Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.

UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email View email address on click.appcast.io if you need a reasonable accommodation to search and/or to apply for a career opportunity.