Accreditation Specialist Senior_ E

Accreditation & Regulatory Compliance Coordinator

At UK King's Daughters, we're not just a healthcare facility — we're a family of dedicated professionals who share a passion for making a meaningful difference in the lives of our patients. We're more than just a place to work; we're a place to grow, thrive, and contribute to our community.

Job Summary:

Responsible for overseeing and coordinating accreditation and regulatory compliance activities to ensure adherence to applicable standards and organizational policies. Develops, implements, and monitors processes to maintain continuous survey readiness across departments. Provides expert guidance, training, and consultation to staff and leadership regarding accreditation requirements and quality improvement. Collaborates with interdisciplinary teams to identify risks, implement corrective actions, and sustain compliance excellence.

Essential Functions:

• Coordinate accreditation and regulatory compliance activities across assigned departments or programs.

• Monitor adherence to accreditation standards and regulatory requirements, identifying gaps and improvement opportunities.

• Develop, implement, and maintain processes to ensure continuous survey readiness.

• Conduct audits, tracers, and assessments to evaluate compliance with organizational and external standards.

• Provide training, education, and consultation to staff and leadership on accreditation and regulatory practices.

• Prepare and maintain documentation required for surveys, inspections, and audits.

• Collaborate with quality, risk management, and operational leaders to implement corrective action plans.

• Analyze data and prepare reports on compliance trends and performance outcomes for leadership review.

• Serve as a subject matter expert on accreditation standards, updates, and best practices.

• Perform other duties as assigned.

Education Requirement:

Bachelor's degree

Experience Requirement:

5+ years of experience. An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated based on hours worked per week. Volunteer work and internships for academic credit are not counted.

Certifications & Licensures:

Active Registered Nurse (RN) license

Working Conditions:

A. Lifting, pushing, and/or pulling objects up to 50lbs:2. Occasional (< 10% of the time)

B. Lifting, pushing, and/or pulling objects over 50lbs:1. Never

C. Standing or walking with objects up to 10lbs:3. Intermittent (10% - 50% of the time)

D. Standing or walking with objects up to 25lbs:2. Occasional (< 10% of the time)

E. Sitting at the computer workstation for extended periods:3. Intermittent (10% - 50% of the time)

F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials:2. Occasional (< 10% of the time)

G. Repetitive motion:3. Intermittent (10% - 50% of the time)

H. Working at heights above 4 feet:1. Never

I. Working in confined spaces:1. Never

J. Risk of injuries from use of equipment on the job:2. Occasional (< 10% of the time)

K. Job-related travel:2. Occasional (< 10% of the time)

L. Loud noises:1. Never

M. Temperature extremes:1. Never

N. Hazardous chemicals and fumes including waste:2. Occasional (< 10% of the time)

O. Radiation:1. Never

P. Burns:1. Never

Q. Cuts/Punctures:2. Occasional (< 10% of the time)

R. Bloodborne/airborne pathogens:2. Occasional (< 10% of the time)

S. Recombinant DNA or viral vectors:1. Never

T. Combative/violent people:1. Never

U. Animal handling (including carcasses):1. Never

V. Please specify other(s) and amount of exposure (i.e. Occasional, Intermittent or Regular): N/A

Physical Demands:

This position requires intermittent sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); intermittent standing or walking with objects weighing up to 10 pounds; occasional standing or walking with objects weighing up to 25 pounds; and occasional lifting, pushing, or pulling objects weighing up to 50 pounds.

Department:

Accreditation & Patient Safety

Shift:

Days (United States of America)

Time Type:

Full time

Address:

2201 Lexington Avenue

City, State:

Ashland, Kentucky