Accreditation Specialist

St. Jude Children's Research Hospital

Accreditation Specialist improving healthcare standards and maintaining accreditation at Texas Children's Hospital. Collaborating on surveys, developing training, and consulting on regulations.

Posted 7/7/2026full-timeHouston • Texas • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

Supports the Continuous Service Readiness program
Participates in the internal mock survey program, which includes planning, development of tools, training, conducting mock surveys, reporting findings and follow-up as needed
Works with leadership to plan, facilitate, participate, and follow-up on findings of consultative surveys.
Participates in actual unannounced JC/CMS/TxHHS surveys. Role includes preplanning, education, active participation in survey, and required follow-up.
Participates in conducting annual ICM. Report findings and develop action plans. Monitor metrics on a monthly basis as required.
Coordinates regulatory educational offerings including internal and external presentations
Oversee JC Accreditation website and communicate to appropriate audiences. Maintains documents necessary for the system.
Oversees and coordinates with IS the installation of Accreditation Manager Plus (AMP) site licenses. Provides education and training to the AMP end users. Represents Accreditation in formal and informal settings at TCH and in the healthcare community.
Represents Accreditation at TCH committee meetings and programs, as assigned.
Prepares agendas, reports, and minutes as assigned, on time and error-free
Provide regulatory consulting and analysis services to TCH IDS staff and physicians.
Serves as TCH liaison to JCR for coordination, scheduling, contracting, and billing of mock survey visits.
Serves as JCR Advisory Panel representative.
Communicates with Joint Commission SIG group for questions regarding interpretation of accreditation issues. Inform appropriate parties of SIG ruling.
Actively commits to the on-going development of self and maintain current knowledge of accreditation and regulatory standards.
Develops regulatory articles and newsletters for the organization error free and on time
Develops presentations with style, accuracy and professionalism as evidenced by error free presentation. Includes not only power point but written material as well.
Maintains up to date knowledge of JC/CMS/TxHHS regulations for all applicable programs, as evidenced by direct observation by leadership.
Conducts consultative mock surveys independently throughout the IDS. Evidenced by direct observation of leadership and customer feedback.
Participation in other departmental operations.
Provide input related to the development of the operating budget.
Acts as a Facilitator or Team Leader on projects as assigned.
Conducts special projects as assigned at the direction of leadership

Requirements

What you’ll need

Required Education: Bachelor’s Degree
Licenses/Certifications: CPHQ; RN or other clinical discipline.
Experience: Minimum 2 years of clinical, quality, and/or accreditation experience.
Skills: Strong communication, analytical skills, regulatory knowledge, and ability to collaborate across departments.

Benefits

Comp & perks

Professional development opportunities

ATS Keywords

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Mock Survey PlanningQuality ImprovementRegulatory ConsultingAction Plan DevelopmentMetrics Monitoring

Soft Skills

CollaborationFacilitationPresentation Skills

Certifications

CPHQRN