Policy & Procedures Coordinator

Education and Work Experience:

• High School Education/GED or equivalent: Required


• Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred


• Five years' relevant experience: Preferred

Essential Functions:

• Coordinates the inputting and maintenance of policies and procedures within the policies and procedures software system. Assures policies and procedures are compliant with Total Joint Commission (TJC), Adventist Health (AH), Centers for Medicare and Medicaid Services (CMS) standards and regulations.


• Collaborates with key individuals, hospital departments, stakeholders, and owners of each policy to obtain all appropriate document approvals and ensure that all content loaded into policy and status is current and complete.


• Assists with report development, as requested by Clinical Data Analyst and/or leadership in Organizational Performance Department.


• Maintains the policies and procedures database by establishing, monitoring, and enforcing standards for policy structure, content, and format. Coordinates maintenance of policies and procedures within the policy management software.


• Provides training and ongoing support to authorized users of the policy management software to ensure consistent adoption and compliance with established processes. . Support Accreditation and Regulatory leaders in survey activities.


• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.