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Job Description

Job Title: Accreditation/Regulatory Specialist
Job ID: 832815499
Status: Full-Time
Regular/Temporary: Regular
Hours: Daylight, Flexible
Shift: Day Job
Facility: Western Psychiatric Institute
Department: Nursing Adminstration
Location: 3811 O'hara Street, Pittsburgh PA 15213


Assists the Director, Accreditation and Regulatory Compliance in ensuring compliance with Joint Commission, Department of Health, Center for Medicare and Medicaid Services, and other applicable regulations and standards. Serves as a liaison for Accreditation & Regulatory Compliance activities in the absence of the Director.


The ideal candidate for this role will preferably have a degree in a Nursing related field, in addition to experience in a Behavioral Health setting. Training and regulatory related experience also preferred.



  • Identify deficiencies in standards and sets priorities for correction.
  • Integrate knowledge and skills in the facilitation of education and implementing actions related to compliance.
  • Monitor and evaluate trends, and follow through on action plans and activities addressing areas of non-compliance.
  • Conduct tracer and education activities with inpatient staff to ensure knowledge and skill in meeting accreditation and regulatory requirements
  • Audit clinical documentation for compliance
  • Advise Director of opportunities for process or practice improvement.
  • Promote and participate in educational activities related to new standards and staff education related to the same.
  • Lead in the development, implementation, and evaluation of education based on learning needs and clinical priorities, standards of nursing care, and nursing policies related to nursing functions and accreditation/regulatory requirements.
  • Demonstrate current knowledge in accreditation standards and exhibit ability to implement action plans related to specific responsibilities.
  • Represent the Department in the absence of the Director.
  • Demonstrate a high level of initiative, work independently, and establish priorities to meet department and organizational goals



  • Bachelor's degree in healthcare related field (or actively pursuing).
  • 5 years experience in acute care is required.
  • Current knowledge of medical care/treatment, Joint Commission standards, federal/state regulations preferred.
  • Expert clinical practice, leadership skills, and critical thinking skills.

    Licensure, Certifications, and Clearances:

    UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $27.98 to $47.14 / hour

Union Position: No

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