Job Information

AdventHealth Accreditation Coordinator in Shawnee, Kansas


Accreditation Coordinator

All the benefits and perks you need for you and your family:

  • Benefits from Day One for eligible employees

  • Paid Days Off from Day One

  • Student Loan Repayment Program

  • Career Development

  • Whole Person Wellbeing Resources

  • Mental Health Resources and Support

  • Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time. Days

Location: 9100 W 74 th Street, Merriam, KS 66204

The community you’ll be caring for:

At AdventHealth Shawnee Mission, formerly Shawnee Mission Medical Center, you're more than just a number on a chart. You're a whole person, who functions best when physically, emotionally, and spiritually fit. Find whole-person care, dedicated teams and staff, and a wide variety of medical services, all at our hospital in Shawnee Mission, Kansas.

The role you’ll contribute:

The Accreditation Coordinator is a part of the Quality / Risk Management team and reports to the Manager of Risk and Patient Safety. The Accreditation Coordinator works collaboratively with leadership to ensure Joint Commission standards and CMS Conditions of Participation compliance. Responsible for Joint Commission continuous readiness for the Hospital, Home Care, Behavioral Health, licensed surgery centers and the bariatric hospital. Also serves as a resource for hospital identified programs seeking Joint Commission Certification and other Accreditations.

The value you’ll bring to the team:

  • Responsible for staying current on CMS Conditions of Participation (CoP) and Joint Commission standards for all levels of care.

  • Responsible for Joint Commission Accreditation/CMS CoP Compliance

  • Ensures continuous survey readiness/compliance with accreditation standards.

  • Conducts or coordinates MOCK surveys, tracers, rounding, compliance audits,

  • Conducts and abstracts chart audits of documentation e.g. clinical pertinence for the medical staff, open records reviews, critical test results, etc.

  • Conduct Focused Standard Assessment for accredited programs

  • Communicates with and educates associates and medical staff on Joint Commission standards

  • Facilitates and coordinates changes necessary to remain compliant-"ever ready activities”

  • Responsible for on-site survey activities (preparation, planning, coordinating, etc.)

  • Serves as a liaison between AHSM’s accredited programs and the Joint Commission

  • Communicates and facilitates necessary changes in order to remain continuously compliant with accreditation standards.

  • Collaborates with other hospital leaders in developing, monitoring, reporting and analyzing accreditation efforts.

  • Proactively seeks opportunities/mechanisms aimed at continually improving patient care, processes and compliance.

  • Recommends and facilitates change to improve based on identified risks.

  • Facilitates the creation of an effective action plan in response to identified issues.

  • Responsible for follow through and oversight for completion and actions plans relating to identified issues, including follow up measures of effectiveness.

  • Working knowledge of Kansas Risk Management statutes, and Patient Safety Organization (PSO) requirements, as it pertains to patient safety and quality.


The expertise and experiences you’ll need to succeed:

  • Bachelors Degree in Nursing or healthcare related field required

  • 2-5 years of clinical nursing experience or healthcare related experience required

  • Registered Nurse License in KS or applicable licensure in the state of Kansas

  • CPHQ (Certified Professional in Healthcare Quality) preferred

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

Category: Quality/Clinical Effectiveness

Organization: AdventHealth Shawnee Mission

Schedule: 1 - Day

Shift: AdventHealth Shawnee Mission

Req ID: 22046244

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.