WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you’ll discover a culture of teamwork, professionalism, and a rewarding career!

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

• Education
  Bachelor’s Degree in healthcare administration, nursing, public health, or related field

• Experience
  3 years of experience in healthcare accreditation, regulatory affairs, or quality management, preferably in behavioral health

Preferred

• Education
  Master’s Degree in healthcare administration, nursing, public health, or related field

• Experience
  5 years of experience in healthcare accreditation, regulatory affairs, or quality management, preferably in behavioral health

JOB DUTIES

• Collaborates with clinical and administrative departments to ensure policies, procedures, and practices comply with accreditation, regulatory, ethical, and patient safety standards.
• Reviews, evaluates, and revises organizational policies and procedures to ensure compliance with CMS, TJC, and other applicable regulatory requirements, incorporating evidence-based practice.
• Interprets accreditation standards, identifies compliance gaps, and facilitates implementation of corrective action plans, monitoring tools, and sustainability measures.
• Coordinates and supports continuous survey readiness activities, including tracers, readiness rounds, self-assessments, and preparation for accreditation and certification surveys.
• Maintains and manages the electronic policy and procedure repository, providing guidance and support to departments on policy development and maintenance.
• Partners with subject matter experts to develop, document, and streamline policies, procedures, workflows, and process maps into clear, concise, and standardized formats.
• Supports regulatory submissions and follow-up activities, including FSA/PPR, Evidence of Standards Compliance (ESC), responses to complaints, and survey action plans.
• Communicates new and revised policies in a timely manner and collaborates with Education and leadership to support effective deployment and staff understanding.
• Monitors regulatory trends and evolving accreditation standards, providing education, guidance, and interpretation to leadership, committees, and staff.
• Communicates unresolved compliance issues to management and leadership, collaborates on resolution strategies, and performs additional duties as assigned.

SECURITY AND EEO STATEMENT

Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.