Accreditation Coordinator - RN

Job ID
Clinical - All


Position Purpose


Provides support with accreditation activities to ensure compliance of the accreditation standards. Assists with initiatives necessary to meet organizational objectives for accreditation by pro-actively coordinating, monitoring, and evaluating these activities throughout the health plan in order to attain and maintain full accreditation status.


Scope of Position


The Accreditation Coordinator assists the Accreditation Director in obtaining quality evidence required for all aspects of the accreditation activities. Serves as a primary resource and subject matter expert for the readiness assessment, preparation and submission for surveys. Pro-actively monitors compliance with the standards and serves as a liaison to departments and ensures the submitted evidence meets the requirements. Assists with training for departments falling under the scope of the accreditation


Principal Responsibilities


  • Collaborates with departments as needed to ensure required documents and reports are current and available as they pertain to the accreditation process.
  • Identifies, analyzes, develops, and executes solutions for potential accreditation compliance gaps company-wide until gap is closed. Provides program management for assigned activities, including process improvement and action plans
  • Assist with initial and on-going education regarding accreditation standards and requirements.

  • Make effective decisions by assessing and evaluating a variety of information and resources.
  • Develops and maintains auditing, tracking, and reporting tools. Analyzes audit results; identifies opportunities for improvement and, if indicated, recommends corrective actions; and collaborates with the accreditation manager to correct deficiencies. Ensures departments are in compliance with accreditation requirements and audit ready.

  • Assigns and ensures new standards are properly assigned for implementation.

  • Provides regular reports on survey readiness to designated committees.
  • Develops and maintains basic information surveyors will request at the time of survey; this includes maintaining the resource guides i.e. shared folders, NCQA ISS, etc.
  • Assist in maintaining current operational policies and procedures for specified accreditation standards.
  • Provide assistance and support to staff needing additional guidance regarding the accreditation evidence required.



Core Competencies


  • Communicate effectively with all departments and staff within the organization who are involved with the accreditation process.
  • Effectively function in a team environment to effect change and achieve desired outcomes.
  • Outcome oriented, analytical, problem-solving, and decision-making abilities.
  • Self-motivated and able to complete assignments with minimal guidance.
  • Manage complex multiple tasks concurrently to achieve the desired outcomes within the mandated time-frames
  • Loyal and committed to the organizational objectives, mission, and vision of Peoples Health
  • Flexible in time commitment to the organization based on departmental priorities
  • Effective, organized and detail oriented approach to complex processes
  • Professional in conduct and interactions with others
  • Recognizes and accepts cultural diversity

Education / Experience

  • Diploma or Degree in Nursing required; BSN highly preferred. 
  • Must have a current active Louisiana RN license to practice. 
  • Minimum of 3 years experience in a clinical setting is required. 
  • Previous Managed Care experience highly preferred. 
  • Knowledge of and experience with the accreditation process highly preferred. 
  • Knowledge of Word, Excel and Power-Point highly preferred. 


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