Job Description

The RN, Registered Nurse, Safety & Accreditation Coordinator, plays a critical role in supporting hospital-wide accreditation, regulatory compliance, and patient/staff safety. This position ensures continuous readiness for surveys and inspections, facilitates compliance with safety standards, and works collaboratively across departments to promote a safe and compliant care environment.

Key Responsibilities - Highlights

Accreditation & Compliance

• Coordinate all activities related to Joint Commission readiness and surveillance and ensure compliance with federal and state regulatory standards.
• Conduct compliance rounds and assist departments with interpreting and applying accreditation standards.

Safety Oversight

• Participate in environmental and patient safety rounds across the organization.
• Identify and assess safety hazards; assist with the investigation and resolution of safety incidents.
• Assist in designing systems and processes that support a culture of safety.

Data & Reporting

• Create and maintain databases to track safety trends and compliance metrics.
• Distribute timely and accurate reports to stakeholders on a routine.

Administrative Support

• Provide general administrative support for Safety and Quality Leadership.
• Complete additional projects and assignments as directed.

Organizational Responsibilities

• Attend and actively participate in team meetings, maintaining accountability for shared information.
• Comply with all hospital policies, procedures, and regulatory requirements.
• Remain flexible and available to schedule adjustments as needed.

Qualifications

Education & Experience:

• BSN, RN, Registered Nurse required
• At least 3 years of progressive experience in healthcare or safety-related work required.
• Previous experience with the Joint Commission strongly preferred.

Knowledge & Skills:

• Strong analytical, organizational, and problem-solving skills.
• High level of professionalism, discretion, and interpersonal communication.
• Proficient in Microsoft Office, data entry, spreadsheets, and databases.

Working Conditions

• Hospital environment with patient, visitor, and staff interactions.
• Occasional travel to off-site locations and flexibility in schedule as needed.
• Physical ability and stamina are required to perform essential job functions.

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