Clinical Accreditation Specialist

2 weeks ago


Houston, Texas, United States The University of Texas M. D. Anderson Cancer Center Full time
Clinical Accreditation Specialist (RN)| Accreditation & Regulatory Readiness Department


The primary purpose of the Clinical Accreditation Specialist is to perform analytical and project management work that supports the accreditation process, assist in the assessment, measurement and reporting of ongoing compliance with Joint Commission standards and other regulatory requirements, and assist with data systems that support compliance.


The ideal candidate will have a Bachelor's Degree in Nursing with at least five years of healthcare experience to include knowledge of Accreditation, Joint Commission and CMS Survey process.

Accreditation Readiness Activities

  • Organize and lead mock tracer activities to include reporting as indicated
  • Collaborate with assigned Joint Commission chapter leaders to evaluate and maintain readiness
  • Ensure that the data for accreditation chapters is current and remains available for impending accreditation/regulatory site visits.
  • Prepare and support chapter leaders and the organization in accreditation readiness efforts.
  • Participate in Failure Mode and Effect Analysis (FMEA), when indicated
Education and Collaboration

  • Provide input into interpretation of operational and clinically related standards
  • Provide educational support when indicated
  • Maintain, support, and provide education for accreditation activities and databases/systems (e.g., Midas+ Comply).
  • Ensure reporting of compliance and/or address needs for readiness efforts.
  • Collaborate with all institutional disciplines to ensure preparedness and compliance with accreditation and regulatory surveys/activities.
Special Projects and Duties

  • Works closely and effectively with stakeholders from all disciplines, such as nursing, pharmacy, and medical staff.
  • Conducts and/or participates in special projects/audits as assigned or necessary.
Other duties as assigned.

Bachelor's Degree in Nursing or healthcare related field. Five years of healthcare experience. Current State of Texas Professional Nursing license (RN). Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) certification.

It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law.

Additional Information

  • Requisition ID: 168182
  • Employment Status: Full-Time
  • Employee Status: Regular
  • Work Week: Days
  • Minimum Salary: US Dollar (USD) 75,000
  • Midpoint Salary: US Dollar (USD) 93,500
  • Maximum Salary : US Dollar (USD) 112,000
*FLSA: exempt and not eligible for overtime pay

  • Fund Type: Hard
  • Work Location: Hybrid Onsite/Remote
  • Pivotal Position: Yes
  • Referral Bonus Available?: Yes
  • Relocation Assistance Available?: Yes
  • Science Jobs: No


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