Job Description

Job Description

Job Description

Why us?

We know it’s not just about finding a job. It’s about finding a place where you are respected, valued, and where your work is purposeful and fulfilling. A place where your talent is recognized, professional development is encouraged and career advancement is possible.

Job Summary

• Coordinates all accreditation and regulatory readiness activities across departments, ensuring ongoing compliance with standards from accrediting bodies such as The Joint Commission (TJC), CMS, and state agencies.
• Serves as liaison with external accrediting and regulatory agencies, supporting survey preparation, coordination, and follow-up.
• Facilitates multidisciplinary teams to address compliance gaps and implement corrective action plans.
• Conducts routine compliance rounds in clinical and non-clinical areas, identifying issues, educating staff, and escalating concerns when needed.
• Provides education and training on accreditation standards, performance improvement methodologies, and regulatory changes to hospital staff and leadership.
• Collaborates with hospital leadership and medical staff to track and trend performance indicators related to quality, safety, and accreditation.
• Assists departments in developing and evaluating policies and procedures to ensure alignment with accreditation and licensure standards.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• Associate Degree in Nursing, Healthcare Administration, Public Health, or a related field required
• Bachelor's Degree in Nursing, Healthcare Administration, Public Health, or a related field preferred
• 3-5 years of experience in accreditation, regulatory compliance, or quality improvement in a healthcare setting required
• Prior experience coordinating Joint Commission or CMS survey readiness preferred

Knowledge, Skills and Abilities

• Knowledge of accreditation and regulatory requirements applicable to hospitals and healthcare facilities.
• Strong understanding of performance improvement tools, root cause analysis, and process mapping.
• Effective communication and facilitation skills with the ability to work across clinical and administrative teams.
• Ability to analyze and interpret data to identify trends and inform decision-making.
• Proficiency in Google Suite or Microsoft Office and electronic quality/compliance reporting tools.

Licenses and Certifications

• CPHQ - Certified Professional in Healthcare Quality preferred or
• CHCQM - Certified Healthcare Quality Management preferred
• RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred

Who we are!

We are a 168-bed Joint Commission accredited acute care facility serving Las Cruces and southern New Mexico. Since our opening in 2002, our hospital has continually grown to serve the needs of our community and surrounding areas. A legacy of rich history, culture and natural beauty; Las Cruces remains one of the Southwest’s best kept secrets. With a thriving arts scene, a focus on downtown, adjacent national monuments and plenty of Southwest charm, there’s always something for you and your family to do or see in Las Cruces. Often recognized nationally as a top place to live and retire, Las Cruces offers a welcoming community. MountainView Regional Medical Center is Las Cruces Strong! Start your new job search here and see why we are ….Proud to be MountainView!

We are an Equal Opportunity Employer (M/F/M/V) and welcome you to apply.

#INDNUR

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