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Work Schedule/Shift


Job ID


Req. No


Job Title

RN Accreditation Coordinator- Quality Improvement


CHRISTUS Good Shepherd




Not Defined






GSMC - Longview-15500


700 E. Marshall Ave.
Longview, TX  75601


Full Time

Apply Now RN Accreditation Coordinator- Quality Improvement Job in Longview


*Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable) to include CMS, State, and TJC for Marshall, Longview, and Ambulatory Clinics.

* Interpretation of relevance of standards in relation to hospital/department policies and practices.

* Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements.

* Conducts patient and system tracers in patient care areas through observation of practice.

* Collects, analyzes and reports data in support of continuous readiness activities.

* Disseminates the results of audits and surveillance results as needed.

* Assist in assuring accuracy and timeliness in submission of corrective action plans to internal stakeholders and external agencies.

*Designs and implements survey management plans

*Develops and delivers staff and leadership education related to regulatory and accreditation standards and processes.

*Facilitates monthly Accreditation Readiness Committee to include agenda planning, minutes, presentations as needed.

  • Certification/Licensure
    • CPR required. CPHQ and/or HACP specialty certification or must obtain within 2 years.
    • Current RN license with the ability to practice in the state of Texas.
  • Education
    • Graduate of a school of nursing required. Bachelor in Nursing/Science is preferred.
  • Experience
    • 2 years' experience in quality or regulatory compliance to include at least 1 year responsible for compliance for JCAHO and/or other Accreditation agencies in an acute care setting preferred.
  • Other Skills/Competencies
    • Ability to perform the essential functions of this position, with or without reasonable accommodation and without posing a direct threat to the health and safety of self or others. Ability to comply with all Good Shepherd policies and procedures that are job-related and consistent with business necessity. Ability to effectively communicate with patients and provide competent care as appropriate to the ages of patients served by this position.
  • Computer Skills
    • Computer literacy is desired.
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