Clinical/Regulatory Accreditation Coordinator

Posted: 24-Jul-26 • Fort Worth, Texas

About the role

The Clinical Accreditation Coordinator is a highly collaborative role responsible for promoting a culture of continuous survey readiness, quality, and patient safety throughout Baylor Scott & White Health. As an internal consultant and trusted resource, this position partners with clinical leaders and interdisciplinary teams to prepare for accreditation surveys, interpret standards, evaluate clinical processes, and implement best practices that support exceptional patient care.

This role is ideal for a healthcare professional with a clinical background—such as an RN, Respiratory Therapist, Pharmacy Technician, Physical Therapist, or Health Information Management professional—who enjoys educating others, solving complex problems, leading improvement initiatives, and influencing positive change across the organization.

Responsibilities

• Lead and coordinate accreditation and continuous survey readiness activities across the hospital, ensuring alignment with Joint Commission, CMS Conditions of Participation (CoPs), Texas Department of State Health Services (TDSHS), and other regulatory standards.
• Partner with clinical leaders, physicians, nursing, ancillary departments, and operational teams to evaluate current practices, identify opportunities for improvement, and promote ongoing accreditation readiness.
• Conduct mock surveys, tracers, documentation reviews, and departmental assessments to evaluate readiness and support continuous quality improvement.
• Review organizational policies, procedures, and clinical processes to ensure they reflect current accreditation standards, regulatory requirements, and evidence-based practices.
• Collaborate with department leaders to develop, implement, and monitor action plans that address survey findings and strengthen organizational performance.
• Prepare written responses, documentation, and corrective action plans related to accreditation surveys, regulatory reviews, and identified opportunities for improvement.
• Develop and deliver education, training, and resources to support staff understanding of accreditation standards and regulatory requirements.

Requirements

• Strong clinical or healthcare operations background.
• Passion for educating others, building collaborative relationships, and driving continuous improvement through accreditation and quality initiatives.
• Experience with Joint Commission standards, healthcare survey readiness, clinical documentation, and performance improvement is highly valued.