University of Utah Health Accreditation Specialist in SALT LAKE CITY, Utah


As a patient-focused organization, the University of Utah Health Care exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health Care seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission. EO/AA

This position coordinates the regulatory activities of the Hospitals and Clinics to meet the requirements of multiple regulating agencies for accreditation.

This position is not responsible for providing care to patients.


  • Researches and analyzes DNV, ISO 9001, JCAHO, HCFA, State and other regulatory agency requirements and issues, and educates staff accordingly.

  • Facilitates quality improvement activities as directed.

  • Develops and performs internal audits and creates self-assessment tools in collaboration with operational managers and directors.

  • Analyzes reports and data such as regulatory surveys, self-assessments or survey readiness and investigations; develops summaries and recommended action plans; assist managers/directors in maintaining survey readiness.

  • Coordinates and performs activities relative to the regulatory surveys.

  • Responsible for obtaining the Hospital and Clinics licensures by completing the appropriate documentation.

  • Provides consultative services to all levels of the organization on accreditation/regulatory content. Serves as the expert source on accreditation.

  • Participates in hospital meetings, committees, and teams.

  • Ensures availability of current references of regulatory agency standards and communicates changes to management.

  • Participates in patient safety improvement work or teams as directed.

Knowledge / Skills / Abilities

  • Ability to perform the essential functions of the job as outlined above.

  • Demonstrated knowledge of DNV, ISO 9001, Joint Commission and HCFA requirements.

  • Demonstrated human relation and effective communication skills.

  • Ability to effectively assist the hospitals and clinics in preparation for regulatory surveys by communicating all necessary information to the appropriate departments and recommending actions to maintain compliance.

  • Ability to serve as the primary contact and expert regarding regulatory agency standards governing the hospital and clinics.

  • Demonstrated computer skills including database analysis.

  • Ability to multitask and complete follow-up on assigned tasks.

  • Ability to have a collaborative investigative skill to perform audits.

  • Able to work independently as well as in team functions.




  • Bachelor's degree in a health-related field or equivalency.

  • Four years working in a patient care clinical area.

Qualifications (Preferred):


  • Master's degree in a health-related field.

  • Current RN License

  • Previous management experience.

  • Two years experience in regulatory accreditation such as Joint Commission, DNV, or ISO 9001.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

  • This is a sedentary position that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.

Physical Requirements:

Non Indicated

Requisition Number 25718

Reg/Temp Regular

Employment Type Full-Time

Shift Day

Work Schedule Monday - Friday

Location Name University of Utah Hospital

Patient Care? No


State UT


Category Clerical / Office Support

The University of Utah Health Care is an Affirmative Action/Equal Opportunity employer. Upon request, reasonable accommodations in the application process will be provided to individuals with disabilities. The University of Utah Health Care is committed to diversity in its workforce. Women and minorities are encouraged to apply.