Joint Commission Tracer

Summary:

• Location: New York, New York
• Work Mode: Local
• Duration: 17 weeks, through 12/31/26
• Full Time; 5X8 M-F 9AM-5PM. Must be able to work at any of the 8 main campuses.

Responsibilities:

• Participate in hospital-wide continuous readiness activities to ensure compliance with Joint Commission, CMS, and DOH requirements.
• Serve as a subject matter expert for hospital teams assessing compliance with regulatory standards.
• Collaborate with departments on the implementation of standardized processes for accreditation and regulatory activities.
• Facilitate the development and monitor completion of corrective action plans and related data analysis.
• Lead tracing activities, internal mock surveys, and focused standards assessments.
• Guide operational leaders in responding to surveyor requests and ensure documentation meets survey team requirements.
• Synthesize complex information for operational and senior leaders.
• Identify areas of risk and collaborate on corrective action plans.
• Maintain current knowledge of external standards and regulations.
• Design and deliver educational trainings to enhance organizational knowledge of accreditation and regulatory requirements.
• Serve as a liaison between hospital leadership and surveyors.
• Participate in various hospital and quality committees, work groups, or task forces as assigned.

Requirements:

• Bachelor's Degree
• Minimum 5 years of experience, primarily in healthcare-related roles
• Quality Assurance experience is crucial
• Hospital healthcare experience is a must
• Knowledge of Joint Commission, CMS, and DOH requirements or experience with regulatory survey activity
• Experience with desktop computer applications and advanced skills with Microsoft applications
• Excellent communication skills, both oral and written
• Experience with managing and interpreting data
• Ability to manage multiple activities and meet timelines and deadlines
• Ability to work with a variety of departments and levels of personnel

Preferred Skills:

• Master's degree
• 3 years of Project Management experience