Major Responsibilities

· Responsibilities include all aspects of planning and implementation of compliance activities for accreditation and or regulatory agencies requirements, including Joint Commission, State and CMS

· Coordinates on-site surveys, mock surveys, and consultations

· Prepares and presents reports on compliance status

· Coordinates organization sustainability plan for ongoing readiness

· Develops methodologies and activities to support departments in achieving and exceeding continual compliance requirements

· Assesses, monitors, and recommends, as appropriate, activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards

· Educates leaders, staff, medical staff, and other stakeholders on the accreditation process and requirements

· Provides staff support to committees and work groups charged with accreditation steering and oversight

Qualifications

· RN required bachelor's degree preferred

· CPHQ or HACP preferred

· 5 years of clinical acute care hospital experience

· Current compliance experience with standards, requirements, and regulations of The Joint Commission (TJC) on Accreditation of Healthcare Organizations, the Centers for Medicare, and Medicaid Services (CMS), including TJC hospital accreditation requirements, CMS Conditions of Participation and State Hospital licensing requirements

· Experience in project management, group facilitation, and leadership group presentations preferred

· Must be able to adapt to change and adjust job responsibilities as the organization and outside regulatory agencies mandate. Must possess a solid understanding of team dynamics

· Excellent verbal and written communication skills and relationship building

· Available to travel within other CHRISTUS Good Shepherd locations

Work Type:

Full Time

If you have any questions or need assistance with the application process, please reach out to Courtney Mize at courtney.mize@christushealth.org or 903-276-4512. 

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About CHRISTUS Health

CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.

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