Accreditation Readiness Coordinator (RN/LVN Preferred) - FT - Days

Professional Edinburg, Texas


Position at DHR Health


Under the direct supervision of the Supervisor, the Coordinator supports the overall patient safety program across the continuum of care at DHR. The Coordinator is responsible for participating in short-term and long-term strategies to ensure the organization’s mission, vision, and values are carried out through the delivery of high quality, cost effective patient care with a high level of integrity.



  • RN/LVN preferred
  • Minimum experience of three (3) years of accreditation/quality experience in a hospital setting preferred
  • Experience in coordinating TJC preparation and participation in State and CMS surveys within the last three (3) years preferred
  • Computer skills required with proficiency in Microsoft Office Suite
  • Effective written and verbal communication skills required
  • Bilingual – English/Spanish preferred
  • Current valid driver’s license required



  • Three (3) years of accreditation experience in the acute healthcare setting preferred
  • Strong organizational, interpersonal, management and leadership skills




  • Work collaboratively with hospital and medical staff to achieve transformational change
  • Use high level of organizational skills to manage assignments
  • Draft, revise, and enforce policies and procedures in accordance with the mission, vision, regulations and standards
  • Provide education to the hospital and medical staff around accreditation initiatives
  • Assist with performance and process improvement activities throughout the hospital
  • Conduct audits, data abstraction, and chart reviews as assigned and input information into appropriate software or tool
  • Provide timely feedback and support to stakeholders
  • Generate and disseminate reports to stakeholders
  • Assist department managers with preparation for various committee presentations
  • Participate in regulatory/accreditation/certification surveys, i.e., TJC, State Licensing Review, HCFA (CMS) Validation surveys as assigned
  • Develop and analyze data to identify trends, develop action plans, and implement program modification to improve performance
  • Coordinate the quality improvement and patient safety programs at DHR 
  • Travel to other hospital locations as needed according to assignments
  • Other duties as assigned




  1. Accreditation Readiness Supervisor →        Director of Accreditation and Patient Safety   →       
  2. VP of Quality, Safety & Accreditations → 4. Physician Executive