Commission Specialist

Job Title: Joint Commission Tracer (Contract)

(Must be able to work at any of the 8 main campuses; may be asked to float between locations based on operational needs.)

Department: Quality / Regulatory Compliance

Contract Duration: Through 12/31/2026 (17 Weeks)

Pay range: $45/hr to $55/hr

Position Overview

We are seeking an experienced Joint Commission Tracer to support hospital-wide continuous readiness activities and ensure ongoing compliance with Joint Commission, CMS, and Department of Health (DOH) standards. This role will serve as a subject matter expert for accreditation and regulatory requirements, collaborating with hospital leadership, clinical teams, and operational departments to identify risks, implement corrective actions, and maintain regulatory readiness.

Key Responsibilities

• Lead and support continuous readiness activities related to Joint Commission, CMS, and DOH compliance.
• Conduct tracing activities, mock surveys, focused standards assessments, and readiness reviews.
• Assess compliance with accreditation and regulatory standards and identify areas of risk.
• Develop, monitor, and track corrective action plans.
• Review and interpret departmental and hospital-wide data to measure compliance and progress.
• Serve as a liaison between hospital leadership and surveyors during regulatory surveys.
• Respond to surveyor requests and guide operational leaders in preparing required documentation.
• Collaborate with departments, service lines, and clinical units to implement standardized regulatory processes.
• Design and deliver education and training programs related to accreditation and regulatory standards.
• Manage Focused Standards Assessment (FSA) teams and regulatory readiness initiatives.
• Maintain centralized records and reporting of regulatory and survey activities.
• Participate in quality committees, workgroups, and enterprise-wide quality improvement initiatives.
• Project manage assigned quality and regulatory goals.

Required Qualifications

Education

• Bachelor's Degree required
• Master's Degree preferred

Experience

• Minimum 5 years of healthcare-related experience
• Strong Quality Assurance experience required
• Hospital healthcare experience is mandatory
• Knowledge of Joint Commission, CMS, and DOH requirements and/or regulatory survey experience required
• Experience managing and interpreting data
• Advanced proficiency with Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and web-based applications
• Excellent written and verbal communication skills
• Ability to manage multiple priorities, timelines, and deadlines

Preferred Experience

• 3+ years of Project Management experience
• Experience planning and leading projects, developing project plans, managing timelines, and supporting project teams

Required Skills

• Regulatory Compliance
• Joint Commission Readiness
• CMS & DOH Standards
• Quality Assurance
• Data Analysis & Reporting
• Project Management
• Process Improvement
• Survey Preparation & Support
• Stakeholder Management
• Training & Education Development

Pride-Health offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance and employee discounts with preferred vendors.

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