Senior Accreditation Specialist
No salary listed
Senior
Bachelor's, Master's
Houston, TX, USA
In PersonTravel may be required within and outside the Houston metropolitan area.
Risk & ComplianceRegulatory Compliance & Ethics
About the job
Requirements
- A bachelor's degree in nursing or another field relevant to the healthcare industry is required.
- Five years of experience in a hospital setting, preferably in patient care or quality.
- Three years of experience in one or more of the following: healthcare quality, accreditation or regulatory activities in a healthcare setting; performance improvement; patient safety; infection prevention and control; or health information management.
- Two years of experience performing accreditation or regulatory activities in a hospital setting.
- A current state registered nurse license or Healthcare Accreditation Certification Program certification is required.
- Demonstrated knowledge of regulatory and accreditation requirements, such as Centers for Medicare and Medicaid Services, The Joint Commission, DNVGL NIAHO/ISO 9001, or state requirements.
- Demonstrated expertise in quality and performance improvement tools and techniques, process mapping, and flow chart diagrams.
- Intermediate computer proficiency with document, spreadsheet, and graphic software, including Microsoft Word, Excel, and PowerPoint.
- Ability to collect qualitative and quantitative data and information, and analyze and solve problems.
- Strong interpersonal skills and demonstrated ability to work with multidisciplinary groups and teams.
- Strong writing and presentation skills, including the ability to articulate information clearly.
- Ability to adapt to changes in work and assignments.
- Ability to work independently with minimal supervision and identify and use available internal and external resources.
- Time management and organizational skills, including the ability to meet deadlines, work under pressure, and manage multiple projects and tasks.
- Ability to handle sensitive issues discreetly, professionally, and confidentially.
- English proficiency in speaking, reading, and writing sufficient to perform the essential job functions, especially those affecting patient or employee safety or security.
- Ability to communicate effectively with patients, physicians, family members, and coworkers using customer-service-focused, positive language.
Responsibilities
- Collaborate and communicate with disciplines across the hospital to evaluate, improve, and sustain regulatory and accreditation readiness, fostering cooperation to maintain compliance.
- Partner with hospital leadership to establish a proactive review process for regulatory, accreditation, and certification requirements and assess vulnerabilities to compliance.
- Work with hospital leadership to assign teams to develop corrective actions in response to survey findings and facilitate development and implementation of corrective action processes.
- Provide guidance and direction for on-site or written responses and resolution of regulatory or accreditation surveys or complaint investigations.
- Support and participate in pre-survey, on-site survey, and post-survey activities for accreditation, regulatory, and disease-specific certification programs.
- Function as a consultant and surveyor, and conduct internal surveys using ISO 9001 process audit tools and techniques to assess ongoing survey readiness.
- Communicate survey findings to Quality and Patient Safety leadership and other hospital quality and patient safety departments.
- Communicate updates to regulatory, accreditation, and certification standards, and support, guide, assess, and evaluate hospital implementation of compliant processes and practices.
- Provide education and training related to regulatory and accreditation requirements.
- Serve as a primary contact with accreditation and regulatory agencies and independently manage hospital profile information.
- Facilitate survey corrective action processes and review and evaluate their implementation, effectiveness, and sustainability.
- Track, trend, and analyze survey nonconformities, and identify improvement opportunities and best practices.
- Develop and evaluate an ongoing regulatory and accreditation readiness program that promotes continual improvement, including ISO 9001 Quality Management and gap analyses.
- Facilitate resolution of survey nonconformities through collaborative, proactive action plans.
- Participate in annual budget preparation, expense projections, and justifications.
- Use department resources and supplies efficiently and cost-effectively, and recommend expense reductions.
- Stay current with regulatory, accreditation, and certification changes through conferences, online learning, program materials, research, and professional journals.
- Communicate innovative and best practices to hospital quality and patient safety departments and leadership.
- Identify opportunities to align policies and procedures with regulatory and accreditation requirements.
- Enhance continual improvement by acquiring, using, and teaching performance improvement concepts and techniques, including ISO 9001 and Lean.
Desired Qualifications
- A master's degree in a healthcare- or business-related field is preferred.
- Experience in patient care or quality in a hospital setting is preferred.
- One or more of the following certifications is preferred: Certified Professional in Healthcare Quality (NAHQ), Certified Quality Auditor (ASQ), or Certification Specialist in Healthcare Accreditation (HACP).
About the company
Houston Methodist operates a nonprofit academic medical center and a system of eight hospitals in the Greater Houston area. It delivers fee-for-service medical care across specialties such as cancer, heart and vascular care, organ transplantation, neurosciences, orthopedics, and digestive disorders, including care for thousands of international patients. The system combines patient care with research and education through the Houston Methodist Research Institute and a supporting foundation, and it partners with Weill Cornell Medicine, Texas A&M University, and Rice University to run joint programs like EnMed and a broad clinical trials program. Its goal is to improve patient outcomes by providing high-quality medical care while expanding research, education, and clinical trials through collaborations and shared expertise.
Company Size
10,001+
Company Stage
N/A
Total Funding
N/A
Headquarters
Houston, Texas
Founded
2008
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Simplify's Take
What believers are saying
- U.S. News ranked Houston Methodist Hospital No. 1 in Texas on August 4, 2026.
- Cypress Hospital announced a $100 million expansion on March 27, 2026.
- Houston Methodist broadened BioButton monitoring across inpatient care in 2026.
What critics are saying
- A July 2026 stabbing lawsuit targets Texas Medical Center security after an employee attack.
- Memorial Hermann and Baylor St. Luke’s crowd Houston’s rankings, compressing market share.
- A catastrophic patient-safety or security failure breaks referral trust across Texas Medical Center.
What makes Houston Methodist unique
- Weill Cornell Medicine remains Houston Methodist’s primary academic affiliate in 2026.
- EnMed with Texas A&M blends MD and engineering training inside the Texas Medical Center.
- Its research engine supports 1,900-plus protocols and active clinical trials as of September 2026.
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Benefits
- Flexible Work Hours