Quality and Accreditation Coordinator

Quality and Accreditation - 108385 Front Royal, Virginia Winchester, Virginia Full-Time (Primarily Day Shifts)

Please Note: To protect our patients, our workforce and our community, Valley Health is requiring that all newly hired employees and internal transfers (current employees requesting internal transfers) must have received at least one COVID-19 vaccination dose. Newly hired Applicants (those not currently employed by Valley Health) who have been offered a position will have to provide documentation of their vaccination status at the time of their Employee Health appointment. For internal transfers, Employee Health will contact you if they have questions around your vaccination status. Valley Health has a process for applicants who have been offered a position to request an exemption or deferral for medical or religious reasons. To search for vaccine locations, visit vaccines.gov.


  • Entity: Warren Memorial Hospital
  • Shift: Day

Who We Are

Valley Health System is a not-for-profit network of hospitals, urgent cares, physician practices, and services. Expanding across Virginia, West Virginia, and Maryland, we are devoted to the health of all who call our 18-county area home.

A vital resource for healthcare, we are the region’s largest employer, a dependable community partner, and are at the leading edge of clinical innovations.

We are looking for passionate, innovative, and caring people who will each bring their unique skills and perspectives to our workplace.

What You Will Do:

The incumbent is responsible for the practice and advancement of all hospital operations as relates to accreditation and regulatory compliance. Accreditation readiness includes developing, coordinating, and monitoring the effectiveness of the all programs related to standards of Joint Commission and CMS. Develops, educates, coordinates and ensures accreditation readiness. The incumbent will influence the practices of patient care providers through policy setting and through monitoring practices and patient outcomes. Develops and presents necessary educational programs and presentations to all customers within the facility for accreditation. Compiles statistics for monthly, quarterly, and annual reporting .
The position will be responsible for the program development of an integrated approach to continual accreditation readiness by facilitating and coordinating education, tracer activities, mock exercise, developing tools and policies, and coordinating the use of external consultants.
The incumbent will assist and lead quality review initiatives toward the journey of high reliability. The incumbent will serve as an expert resource and conduct root cause analysis/human factor analyses.

What You Will Bring:


Bachelors required

Certification & Licensures
Licensed or eligible for licensure in Commonwealth of Virginia preferred

Demonstrated leadership skills required
Computer and clinical systems experience with emphasis on Epic EMR required
Demonstrated knowledge of quality/performance improvement initiatives with a focus on maintaining patient safety and positive patient experience required
Demonstrated knowledge of Joint Commission, CMS and State regulatory and compliance standards
Demonstrated knowledge and understanding of factors impacting employee engagement and ability to make recommendations for improvement as needed
Demonstrated track record in building programs, staff and physician relationships, process improvement programs, and database management required
Demonstrated verbal and written communication skills, well developed interpersonal skills, including group facilitation required
Demonstrate the ability to be creative, innovative and flexible in responding to changing needs/priorities required

What You Will Get:

- Competitive salary
- Flexible scheduling
- Health Insurance
- Paid Time Off
- Wellness Program
- Tuition Assistance
- Retirement Plan
- Life Insurance

*some benefits are subject to change due to job status

We celebrate, support, and thrive on our differences for the benefit of our employees, our patients, and the communities we serve.
We are neighbors caring for neighbors, and our goal is always to help those we serve get well, feel well, and stay well.


Criminal Background Checks
VA State Police
3rd party Background Check

FLSA Classification


Physical Demands
6 A Customer Service