Summary

Join Carroll Hospital's Performance Improvement team as an Accreditation and Regulatory Readiness Specialist where you will be responsible for leading system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs) as well as other state and federal regulatory agencies. This includes facilitating and ensuring ongoing readiness for accreditation surveys as well as regulatory complaint investigations

Why join Carroll Hospital?

Join a growing hospital system actively investing in advanced technology, expanded services, and employee career development.Here at Carroll you will work alongside experienced interdisciplinary teams across high-acuity patient populations.

Responsibilities

• Ensure continuous regulatory readiness and compliance with accreditation, certification, and regulatory standards.
• Interpret regulatory, accreditation, and disease-specific care requirements and align them with hospital and clinic policies.
• Conduct patient and system tracers through direct observation to assess compliance and identify improvement opportunities.
• Collaborate with quality teams and organizational leaders to develop action plans and drive performance improvement initiatives.
• Provide regulatory readiness training and orientation for new leaders and staff, and support compliance-related committees and workgroups.
• Maintain organized documentation systems, databases, and information sources for accreditation, quality initiatives, and regulatory reporting.
• Collect, analyze, and report compliance and performance data to support continuous readiness and quality improvement efforts.
• Perform medical record audits, communicate findings, track corrective actions, and ensure timely submission of required reports.
• Stay current on regulatory requirements, CMS, TJC, evidence-based standards, and quality metrics; assist with external surveys and reviews.
• Educate staff on compliance expectations, non-compliance identification and escalation, while maintaining professionalism, confidentiality, and effective stakeholder communication.

Qualifications

Credential Note: Healthcare Related License Preferred

About Carroll Hospital

5-7 years of Hospital experience required

Our communities expect and deserve superior medical treatment, compassionate care, and expert guidance in maintaining their health and well-being. At Carroll Hospital, we offer an uncompromising commitment to the highest quality health care experience for people in all stages of life. We are the heart of health care in our communities.

About LifeBridge Health

LifeBridge Health is a dynamic, purpose-driven health system redefining care delivery across the mid-Atlantic and beyond, anchored by our mission to “improve the health of people in the communities we serve.” Join us to advance health access, elevate patient experiences, and contribute to a system that values bold ideas and community-centered care.

With over 14,000 employees, 130 care locations, and two million annual patient encounters, we combine strategic growth, innovation, and deep community commitment to deliver exceptional care anchored by five leading centers in the Baltimore region.

Our organization thrives on a culture of CARE BRAVELY—where compassion, courage, and urgency drive every decision, empowering teams to shape the future of healthcare.