Regulatory & Accreditation Performance Coordinator at AdventHealth

Date Posted: 10/10/2021


Job Snapshot

  • Job Schedule
  • Location:
    Killeen, TX
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Shift
    1 - Day

Job Description


Accreditation & Regulatory Organizational Performance Coordinator - AdventHealth Central Texas

Location Address: 2201 S Clear Creek Rd., Killeen, TX  76549

Top Reasons to Work At AdventHealth Central Texas, Killeen, TX

  • Our care for patients extend to the spiritual level by praying with patients and families and providing on call, 24 hours, 7 days a week Chaplains for spiritual support.
  • Award winning facility with opportunities to grow both professionally and personally working with great individuals, part of a bigger team that continues to build a world-class culture where you become family.
  • Extraordinary benefits to include tuition reimbursement and on-campus classes.
  • Cost of living is 20 percent lower than the national average
  • Largest school district in the area, with more than 50 elementary, middle, high school, and specialized campuses to choose from
  • Surrounded close to Ft. Hood, Copperas Cove, to Belton and Lampasas with plenty of restaurants, shopping and other family fun events.
  • Miles of scenic trails and parks available for recreational activity

Work Hours/Shift:

Full Time / Days

You Will Be Responsible For:

  • Keeps informed of pending industry changes, trends, and best practices and assesses the potential impact of these changes on organizational processes
  • Interprets regulatory rules or rule changes and ensures that they are communicated through multiple mechanisms, including policies and procedures
  • Manages/assists in ongoing and comprehensive risk assessment to identify compliance gaps that need to be resolved or mitigated
  • Utilizes quality improvement techniques and tools to assist with the development and implementation of detailed action plans to achieve compliance on a system-wide basis
  • Advises managers on how to develop and implement audits to measure the effectiveness of new processes or action plans, including the design of audit tools, sampling methods, and the collation and display of data for analysis

What You Will Need:

  • Bachelor’s degree in Nursing, Public Health, Social Work, or other healthcare field.
  • Required experience with working knowledge of behavioral health care environments related to regulatory requirements.
  • Minimum two years work experience in management of accreditation and regulatory management in a healthcare facility (TJC experience required)
  • Experience/demonstrated success in leadership role, able to communicate and lead improvement and regulatory compliance with success.
  • Demonstrated knowledge and application of:
    • Governmental regulations (to include CMS)
    • Customer service skills and knowledge
    • Data collection, sampling, and analysis
    • Strong organizational skills, time management, and delegation skills
    • Computer skills to include spreadsheets, word processing, email/calendar management, and web based applications.
    • Ability to use logic and reasoning to identify strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
    • Process Improvement Methodology (PDSA, DMAIC, etc) knowledge and use
    • Business and management principles for strategic planning, resource allocation, leadership, and coordination of people and resources.
  • Master’s Degree strongly preferred
  • Joint Commission Accreditation Certification preferred
  • IHI Patient Safety Education preferred

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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