Accreditation and Regulatory Compliance; ARC) Coordinator

Job Category: Support Services

Requisition Number: ACCRE
012773

• Posted :
  October 12, 2026
• Full-Time

Showing 1 location

Job Summary

Responsible for comprehensive health system efforts to maintain continuous compliance with regulatory requirements including Joint Commission standards, National Patient Safety Goals, CMS Conditions of Participation, Maryland COMAR, and other regulatory agencies. Educates hospital staff on regulatory requirements and follow through with compliance to regulations. Actively works with Joint Commission chapter leaders to initiate, develop, and monitor requirements of compliance to regulations.

Promotes a safe, functional and supportive environment within the health system so that quality care and safety are preserved. Assists Health System’s staff to remain in a state of continual readiness for any regulatory survey.

Facilitates and or/supports other quality initiatives of the Accreditation and Regulatory Compliance Division, including but not limited to, Root Cause Analysis and Failure Mode and Effects Analysis.

Ensures compliance with CMS complaints, Department of Health, Office of Health Care Quality Complaints, and Joint Commission Complaints.

This position supports the Frederick Health mission, vision, core values and customer service philosophy and adheres to the Frederick Health Compliance Program, including following all regulatory requirements and the Frederick Health Standards of Behavior.

Essential Functions:

• Acts as point person for tracer process. Ensures process meets TJC standards. Designs, executes and compiles data regarding mock surveys and tracer activities.
• Interacts/interfaces with all members ...

Required

Knowledge, Skills and Abilities:

• Strong clinical knowledge and critical thinking skill to evaluate appropriateness of clinical practice.
• Excellent communication skills, both verbal and written.

Minimum Education , Training, and Experience

Required:

Bachelor’s degree in nursing, Information Systems or health care related field required.

• Three to five years of health care experience in a patient care setting with current knowledge ...

If applicable, must demonstrate ...

___ Neonate (0 thru 30 days)

___ Infant (31 thru 12 months)

___ Child (13 months thru 12 years)

___ Adolescent (13 years thru 17 years)

___ Adult (18 years thru 65 years)

___ Geriatric (66+ years)

If applicable, must demonstrate ...

Sedentary
- Light Work
- Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes). While work is mostly done sitting, a certain amount of walking or standing is often necessary.

Ergonomic Risk Factors:

Repetition:
Repeating the same motion over and ...

Working Conditions:

Bloodborne Pathogens Exposure Risk:
Category B – MAY have exposure to blood or body fluids.

Reporting Relationship:

Reports to Manager/Director of Accreditation and Regulatory Compliance.

Equal Opportunity Employer
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