Job Description

1. Assists with preparation and participates in organizational visits from accrediting agencies.
2. Participates in survey command center activities which may include but is not limited to: keeping track of and fulfilling surveyor requests for environmental logs, policies and procedures, employee files, contracts, etc., responding to emails and phone calls.
3. Assists and participates in organization-wide Joint Commission readiness activities including tracers; monitoring and educating staff in regulatory compliance and hospital policy requirements.
4. Enters tracer data into accreditation tracking tool; reports from these data are provided to staff to use in staff education and improving compliance with Joint Commission standards and CMS Conditions of Participation (COPs).
5. Assists with internal regulatory assessments to evaluate and validate compliance with current standards set forth by various external regulatory agencies.

Qualifications

• Associate’s Degree in Nursing is required. BSN preferred.
• Licensure by the Maryland State Board of Nursing Examiners is required.
• 3 years nursing experience required; regulatory, patient safety, or quality focus is preferred.
• Current experience in collecting and submitting externally reported quality data is preferred.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation

• Pay Range: $31.78-$44.5
• Other Compensation (if applicable):
• Review the 2025-2026 UMMS Benefits Guide

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