Hospital Licensing and Accreditation Specialist - Quality & Performance Improvement - Days - FT

The Hospital Licensing and Accreditation Specialist is responsible for coordinating, monitoring, and maintaining all hospital licensing. This role assists the organization with remaining compliant with federal, state, and local regulations as well as accreditation standards established by organizations such as The Joint Commission (TJC), DNV Healthcare, Centers for Medicare & Medicaid Services (CMS), and other applicable regulatory bodies. The specialist serves as a key liaison among hospital leadership, department managers, surveyors, and regulatory agencies to support continuous readiness and quality improvement initiatives. The Hospital Licensing and Accreditation Specialist will have dual reporting to Quality and Legal.

• Licensing and Regulatory Compliance
  • Coordinate initial and renewal applications for hospital licenses, permits, certifications, and registrations
  • Monitor regulatory requirements and ensure timely submission of all required documentation to government agencies
  • Maintain comprehensive records related to hospital licensure, certifications, and regulatory inspections
  • Facilitate responses to regulatory agencies regarding compliance inquiries, audits, and corrective action plans
• Accreditation
  • Assist with coordination of accreditation preparation activities for organizations such as The Joint Commission, DNV, CMS, and state health departments
  • Assist with mock surveys, tracers, and internal audits to assess compliance with accreditation standards
  • Assist with coordinating survey logistics
  • Assist with monitoring corrective action plans and coordinating timely completion of identified deficiencies
• Performance Improvement and Continuous Readiness
  • Collaborate with clinical and operational leaders to promote ongoing survey readiness
  • Participate in quality improvement and patient safety initiatives related to regulatory compliance
  • Analyze compliance in quality improvement and patient safety initiatives related to regulatory compliance
  • Analyze compliance trends and identify opportunities for process improvement
  • Develop and maintain policies and procedures that support regulatory and accreditation requirements
  • Prepare reports and presentations for executive leadership, compliance committees, and governing boards
• Education Training
  • Assist with education and guidance to hospital staff regarding accreditation standards and regulatory requirements
  • Assist with the development of training materials and compliance resources
  • Assist with orientation and ongoing educational sessions related to licensing, accreditation, and survey readiness
  • Serve as a subject matter expert for MSDH licensing and regulatory compliance matters

Education Requirements:

• Required:
  • High School Diploma/GED
• Preferred:
  • Associate or Bachelor's degree in healthcare related field

Experience Requirements:

• Preferred:
  • Two (2) to four (4) years of experience in a healthcare setting. Experience with document control and maintenance and group facilitation in conjunction with accreditation, compliance, quality management, regulatory affairs, or hospital operations. Knowledge of hospital licensing regulations and accreditation standards.

Knowledge:

• Proficiency with Microsoft Office 365 applications. to include Excel, Power Point, and Outlook

Skills:

• Excellent organizational and project management skills; strong analytical and problem-solving abilities; excellent written and verbal communication skills

Work Environment: Primarily office-based within a healthcare setting. Occasional travel for training, conferences, or regulatory meetings. May require flexible hours during survey, inspections, or accreditation activities.

Physical Demands: Frequent reaching, sitting, walking, and standing may be required. No special coordination beyond that used for normal mobility and handling of everyday objects and materials is needed to perform the Job.

Other Duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.