Clinical Accreditation Specialist

2 weeks ago

Elmira, United States Kinetix Full time

Up to a $25,000 Sign on Bonus for qualified Registered Nurses

*Terms of payment may vary based on experience*


Are you ready to join an organization where delivering high quality patient-centered care, compassion, teamwork, and integrity are the basis for how we work? We are focused on delivering high-quality, safe, cost-effective, socially responsible health care services.


This hospital is an integrated healthcare delivery system and is conveniently located in the Southern Tier and Finger Lakes region of New York, which is known for its charm, scenic settings, and historical significance. We offer competitive pay, benefits, paid time off, tuition reimbursement, and advancement opportunities. We welcome your application.


We are seeking a highly motivated Clinical Accreditation Specialist to join our team. This role is perfect for someone who thrives in a fast-paced environment and is passionate about ensuring regulatory compliance and quality improvement. The Clinical Accreditation Specialist will serve as a consultant for interpreting and applying regulatory standards, including those from The Joint Commission and the Centers for Medicare and Medicaid Services (CMS). The role involves advising on policy development, educating healthcare providers on the relevance of standards, supporting a culture of safe, high-quality patient care, and contributing leadership to enterprise-wide initiatives.


If you are ready to make an impact in healthcare accreditation, apply today


Minimum Qualifications:

  • Active RN license required.
  • Bachelor’s degree in a healthcare-related field; Master’s degree preferred.
  • Minimum of five (5) years of clinical and/or administrative experience in a healthcare setting, including direct experience with accreditation and regulatory bodies such as The Joint Commission, CMS, and state licensing agencies.


Certification(s) (Preferred, not required):

  • Certified Specialist in Healthcare Accreditation (CPHA)
  • Certified Professional in Healthcare Quality (CPHQ)
  • Other relevant certifications in healthcare accreditation or quality improvement.


Required Skills:

  • Proficient knowledge of quality improvement methodologies, tools, and data management.
  • Strong leadership and change management capabilities.
  • Ability to work independently with minimal supervision.
  • Expertise in Microsoft Office Suite; familiarity with software for flow diagrams and lean process mapping.
  • Demonstrate analytical and problem-solving abilities.
  • Effective verbal and written communication skills, including presentation and training abilities.
  • General understanding of medical terminology and the institution’s Electronic Medical Record (EMR) system.


Job Duties & Responsibilities:

  • Lead continuous accreditation readiness activities throughout the organization.
  • Assume daily responsibility for quality improvement and regulatory compliance across the Hospital
  • Provide consultative support to all organizational levels regarding accreditation/regulatory standards, policy interpretation, and integration into clinical and operational processes.
  • Develop and implement a continuous readiness plan to engage all staff and providers in meeting high performance standards.
  • Manage on-site surveys for The Joint Commission and CMS, acting as the primary liaison with survey teams.
  • Oversee survey schedules, activities, and remediation of identified issues.
  • Oversee operational aspects of accreditation applications, assessments of compliance with standards, and the development of corrective action plans.
  • Design and conduct audits to assess the effectiveness of implemented improvements.
  • Organize and deliver education and training on accreditation standards and readiness to all levels of staff, including senior leadership, middle management, physicians, and clinical teams.
  • Partner with Safety & Risk Management and Infection Control to ensure ongoing compliance with National Patient Safety Goals and other patient safety standards.
  • Work alongside Quality Management and Performance Improvement teams to ensure sustained compliance with best practices.
  • Ensure timely production and update of documents required by accrediting bodies and regulators.
  • Support hospital administration’s policy and procedure committee with scheduled reviews and updates.
  • Provide expertise for special projects and other duties as assigned.

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