Accreditation & Licensure Coordinator

York, PA | Professional | Tracking Code: 66705

Job Description:

Under general supervision, provides direction and leadership to the organization by coordinating activities designed to achieve and maintain compliance with the CMS Conditions of Participation, PA Department of Health, The Joint Commission and DNV accreditation as it applies, in both inpatient and outpatient hospital licensed entities. Independently performs a variety of audits, analysis of the data as well as ensure compliance with regulatory audits. Serves as the back-up for on-site surveys and works with others to facilitate system process and outcome improvements and shared communications with spread of best practices.


Duties and Responsibilities


  1. Maintains responsibility for ensuring that all Federal/State/Accreditation Standards related to licensure are being met.
  2. Works closely with the Director to help coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications and challenges.
  3. Schedules and coordinates survey related activities including but not limited to agendas, site visits and educational opportunities.
  4. Educates others in interpretation of standards and assists as needed in planning improvement/compliance. Facilitates the integration of new accreditation, certification and regulatory requirements.
  5. Manages and assigns all mock tracers for the off-site locations as well as analyzing the data, develops and monitors action plans as well as reports results.
  6. Performs structured monthly audits of medical records. Reviews records for completeness, accuracy, legibility and other indicators as indicated.
  7. Compiles data for and prepares regularly scheduled or special reports, analyses and statements, after regulatory accreditation or certification surveys
  8. Analyzes data for significant trends or occurrences. Presents data to the appropriate leadership.
  9. Evaluates procedures, provides communication and action tools to encourage the team’s development of methods to track and ensure sustained improvement over time.
  10. Develops and oversees the implementation of corrective action plans to address survey findings. Monitors and analyzes all data related to action plans and reports results to leadership.
  11. Keeps abreast of appropriate regulatory agency requirements related to accreditation.
  12. Utilizes tracer and environmental rounds findings to initiate improvement. Utilizes Tracer activities as educational opportunity for staff.
  13. Provides ongoing reports and updates of existing and potential regulatory compliance issues to the Director.
  14. Develops collaborative networking relationships with colleagues responsible for regulatory compliance activities.
  15. Serves as a back-up to the Director in her/his absence.
  16. Serves as a key member on the Environment of Care team for both inpatient and outpatient sites.


  • Notes:
    • Other combinations of formal education, training and experience may be considered.


  • Minimum Experience:
    • 5 years
    • Min Field of Expertise: Quality, Patient Safety, Government Regulations; Legal Services; Healthcare and Regulatory Affairs. Experience in a Healthcare environment preferred. 


  • Minimum Education:
    • Bachelor's Degree


  • Skills:
    • Demonstrated leadership skills; Demonstrated knowledge of health care and regulatory affairs; Must have a global view of the Hospital vision and mission; Needs to be analytical, inquisitive, persistent and detail-minded; Just Culture is essential in dealing with possible misconduct; Must possess a work ethic that is fair, moral, objective and discreet; Project management and computer skills are required
James Kane
James Kane
Sr. Talent Acquisition Consultant
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)