Registered Nurse (RN), Accreditation Coordinator

Job Description

At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.

As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.

UC Health is committed to providing an inclusive, equitable and diverse place of employment.

The Accreditation Coordinator is responsible for the preparation and coordination of efforts related to The Joint Commission and other regulatory compliance; and maintaining a constant state of service readiness. This includes maintaining knowledge of all standards, updates to standards and tracking compliance within accreditation database.


  • Coordinates interpretation and evaluation of compliance with The Joint Commission, ODH, ODMH, and CMS standards.
  • In collaboration with the Manager of Accreditation the coordinator chairs Regulatory Committees; provides direction for assigned TJC chapter and standard leads. Assists in performing gap analysis of current state of compliance and formulating action plans, responsibilities, and completion dates to bring organization into compliance.
  • Maintains a working knowledge and understanding of the intent of standards, regulations, and agency scoring.
  • Reviews official TJC publications and provides summary to department manager and director on a monthly basis.
  • Serves as an expert resource for the intent of the standards and communicates to appropriate personnel, organizational management and physicians.
  • Collaborates and serves as a resource for hospital departments for standards set forth by accrediting and regulatory agencies. Assists departments in assessing, planning, implementing and monitoring activities to assure compliance. Assures adequate and appropriate education and communication relative to standards set by accrediting and regulatory agencies.
  • Attends local and regional workshops to stay abreast of changes or revisions in standards and regulations.
  • Assists in review and evaluation of departmental and organizational programs and policies to ensure that they guide reimbursement, comply with the standards and regulations set forth by TJC and other regulatory agencies.
  • Conducts patient tracers to determine current state of readiness to ensure that the hospital staff is prepared for the accreditation process.
  • Mechanisms are developed and maintained to ensure that frontline management is aware of the status of departments in regard to compliance.
  • Implements efforts so that the organization is in a constant state of survey readiness.
  • Checks TJC Extranet site every morning for possible survey postings, email communication, new complaints or sentinel event requests for information and communicates to department leadership.

Data Management:
  • Coordinates data management related to tracking regulatory compliance. Provides routine reports to hospital leadership relative to standards of compliance.
  • Is an expert user for AMP Software system and assists Chapter leads with the scoring and evidence documentation in the system.
  • Maintain ongoing documentation and database related to our required annual Periodic Performance Review. Communicates non-compliance standards, action plans, and measures of success to department leadership.
  • Assists in providing instruction and training to other system users.
  • Assists in creation of reports related to tracking compliance.
  • Reviews survey readiness documents on a quarterly basis and ensure that data is current

Project Management:
  • Promotes a positive working relationship between management, staff, and other departments through effective communication and interpersonal skills
  • Effectively integrates change management theory into communication and training activities.
  • Management is kept informed of the status of activities, problems, and new initiatives.
  • Serve as primary contact point to stakeholders to implement action plans for deficiencies identified during internal audits and external surveys.

  • Assists in coordination of training and communication related to regulatory compliance.
  • Develops, coordinates, and implements both individual and group structured programs in response to learning needs.
  • Principles of adult education and learning theories applied when developing teaching plans and when implementing the instructional process.
  • Assists in the development of content of annually required safety and regulatory information.


Education: Minimum Required: Bachelor's Degree in Healthcare Related Field

License/Certification: Registered Nurse in good standing in the state of Ohio

Experience: Minimum Required: 3 - 5 Years equivalent experience

Join our team to BE UC Health. Be Extraordinary. Be Supported. Be Hope. Apply Today!

About UC Health

UC Health is an integrated academic health system serving Greater Cincinnati and Northern Kentucky. In partnership with the University of Cincinnati, UC Health combines clinical expertise and compassion with research and teaching-a combination that provides patients with options for even the most complex situations. Members of UC Health include: UC Medical Center, West Chester Hospital, Daniel Drake Center for Post-Acute Care, Bridgeway Pointe Assisted Living, University of Cincinnati Physicians and UC Health Ambulatory Services (with more than 900 board-certified clinicians and surgeons), Lindner Center of HOPE and several specialized institutes including: UC Gardner Neuroscience Institute and the University of Cincinnati Cancer Center. Many UC Health locations have received national recognition for outstanding quality and patient satisfaction. Learn more at

Same Posting Description for Internal and External Candidates