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Clinical Accreditation Specialist
The Accreditation & Regulatory Readiness department plays a vital role in ensuring MD Anderson maintains the highest standards of safety, quality, and compliance across the organization. This team partners with clinical, operational, and administrative leaders to support ongoing readiness for Joint Commission surveys and other regulatory requirements, helping to uphold MD Anderson’s commitment to excellence in patient care.
As a Clinical Accreditation Specialist, you will support accreditation readiness through analytical work, project management, and cross-functional collaboration. You will help lead mock tracer activities, support chapter leaders, monitor compliance data, and contribute to education and continuous improvement initiatives that strengthen organizational preparedness. This role offers broad exposure across clinical and operational areas and provides the opportunity to influence systems that directly support patient safety and regulatory excellence.
MD Anderson offers a comprehensive total rewards package, including paid medical benefits, generous paid time off, retirement programs, and professional development opportunities, supporting both career growth and long-term stability.
**The ideal candidate will have experience performing tracers and experience working with surveyors**
JOB SPECIFIC COMPETENCIES
Accreditation Readiness Activities
Organize and lead mock tracer activities to include reporting as indicated.
Collaborate with assigned Joint Commission chapter leaders to evaluate and maintain readiness.
Ensure that the data for accreditation chapters is current and remains available for impending accreditation/regulatory site visits.
Prepare and support chapter leaders and the organization in accreditation readiness efforts.
Participate in Failure Mode and Effect Analysis (FMEA), when indicated.
Education and Collaboration
Provide input into interpretation of operational and clinically related standards.
Provide educational support when indicated.
Maintain, support, and provide education for accreditation activities and databases/systems (e.g., Midas+ Comply).
Ensure reporting of compliance and/or address needs for readiness efforts.
Collaborate with all institutional disciplines to ensure preparedness and compliance with accreditation and regulatory surveys/activities.
Special Projects and Duties
Works closely and effectively with stakeholders from all disciplines, such as nursing, pharmacy, and medical staff.
Conducts and/or participates in special projects/audits as assigned or necessary.
Other duties as assigned.
Required:
• Bachelor's Degree in Nursing, Engineering, Applied or Basic Sciences, Industrial Hygiene, Public Health, Environmental Science, Healthcare Administration, Education, or related
Preferred:
• Master’s Degree
Work Experience
Required:
• 5 years of experience in healthcare or facilities management in a healthcare environment
Preferred:
• 5 years of experience with Joint Commission and regulatory compliance (CMS and/or state) experience; ACOS Commission on Cancer Survey Experience
Licenses and Certifications
Preferred (upon hire):
• RN – Registered Nurse: State of Texas Professional Nursing license (RN) OR
• APRN – Advanced Practice Registered Nurse: Written authorization from the Texas Board of Nursing OR
• PA-C – Physician Assistant: National Commission of Certification of Physician Assistants and licensed by the Texas State Board of Physician Assistant Examiners OR
• CPHQ – Certified Professional in Healthcare Quality: Certified Professional in Healthcare Quality certification by National Association for Healthcare Quality OR
• HACP – Healthcare Accreditation Certification Program: Healthcare Accreditation Certification Program by The Center for Improvement in Healthcare Quality OR
• Certified Safety Professional (CSP): Certified Safety Professional by the Board of Certified Safety Professional (BCSP) OR
• CHSP – Cert Healthcare Safety Prof: Certified Healthcare Safety Professional (CHSP) by Board of Certified Hazard Control Management (BCHCM) OR
• CPH – Certified in Public Health: Certified Public Health Professional (CPH) by the National Board of Public Health Examiners (NBPHE) OR
• CHFM – Cert Healthcare Facility Mgr: Certified Healthcare Facility Manager (CHFM) by the American Hospital Association (AHA) OR
• Certified Joint Commission Professional or equivalent certification in safety, accreditation or regulatory OR
• Certification in a medical discipline such as infection control, oncology nursing, respiratory therapy, medical laboratory scientist, etc.
The University of Texas MD Anderson Cancer Center offers excellent benefits, including medical, dental, paid time off, retirement, tuition benefits, educational opportunities, and individual and team recognition.
This position may be responsible for maintaining the security and integrity of critical infrastructure, as defined in Section 113.001(2) of the Texas Business and Commerce Code and therefore may require routine reviews and screening. The ability to satisfy and maintain all requirements necessary to ensure the continued security and integrity of such infrastructure is a condition of hire and continued employment.
It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state, or local laws unless such distinction is required by law.http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html
