Job Description

This RN - Quality Improvement Coordinator position is FT - days working in a dynamic Quality Department.


Provides central expertise regarding accreditation and licensure standards. Identify, communicate, monitor, and evaluate actions to comply with regulations, standards, and accreditation requirements throughout the organization.

  • Timely analysis of regulatory materials, journals, and newsletters for implications on operations.
  • Develop working relationships with external agency representatives and key contacts to assist understanding of NMC compliance requirements.

Provides leadership for organizational preparation and readiness for regulatory and accreditation surveys.

  • Implements a periodic organizational needs assessment for regulatory compliance.
  • Identify areas of vulnerability and assist area leaders in developing corrective action plans.
  • Identify and communicate areas of success; celebrate and encourage promotion of best practices.

Serves as a liaison to regulatory agencies and accreditation bodies.

  • Provides documentation and other information as required or requested to assure compliance for regulatory and accreditation agencies.
  • Maintain and organize all required documentation support in compliance with requirements.
  • Manage all agency site visits to include scheduling, logistics, and communication within the organization.
  • Oversee the development of delivery and follow-up documentation (i.e. reports, plans, appeals, measures, etc.).

Provides consultation to all departments on the interpretation and application of TJC accreditation standards and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation to maintain ongoing readiness.

Development of mandatory educational material to meet periodic requirements.

Assist area leaders in the development of specific educational material to address areas of    vulnerability for compliance with standards or unique requirements for special accreditation.

Assist the medical center to review all educational materials for regulatory or accreditation   compliance to assure they reflect medical center practice and congruence with each other.


Northwest Medical Center is a 300-bed hospital offering a full range of healthcare services including emergency services, accredited chest pain and heart failure programs, neurology and neurosurgery, outpatient imaging, a nationally accredited surgical weight loss program, total joint program, spine program and stroke center (recognized with Gold Seal designations by The Joint Commission), robotic surgery, GI lab, a free-standing women’s center, inpatient rehabilitation facility, wound care center, five urgent care facilities, and three ambulatory surgery centers. NMC also has several affiliated physician practices including Northwest Allied Physicians offering primary care and a wide range of specialists, Desert Cardiology of Tucson, Heart Center of Southern Arizona and Northwest Heart & Vascular.  NMC is accredited by The Joint Commission and is an equal opportunity employer:  race, gender, disability and Veteran status, and VEVRAA Federal Contractor – priority referral Protected Veterans requested.


Application Instructions

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