Job Description

** GENERAL SUMMARY:**

As a Quality/Accreditation Specialist II, you'll play a pivotal role in shaping organizational excellence and regulatory success. Working with limited direction, you'll design and maintain comprehensive compliance frameworks that keep our organization survey-ready while driving continuous improvement. You'll serve as a trusted internal consultant, translating complex regulatory standards into actionable strategies and partnering with leadership and clinical teams to build a culture of compliance and quality.

** PRINCIPAL DUTIES AND RESPONSIBILITIES:**

Strategic Compliance Leadership

• Partner with corporate and business unit leadership to provide strategic direction and oversight of regulatory compliance across all accreditation bodies (The Joint Commission, DNV, CMS, and state/federal agencies)
• Design and maintain organizational infrastructure that ensures sustained compliance with evolving standards and regulations
• Develop and implement comprehensive readiness plans that position the organization for continuous compliance and successful survey outcomes

Consultation & Subject Matter Expertise

• Serve as the go-to consultant and educator for leadership teams, translating regulatory requirements into practical implementation strategies
• Interpret new regulations and provide expert guidance on compliance implications across the organization
• Lead resolution of complex compliance challenges by providing evidence-based strategies that meet regulatory intent
• Develop and review policies and procedures to ensure alignment with regulatory requirements

Readiness & Survey Management

• Coordinate agency-specific accreditation requirements and manage all aspects of on-site surveys and unannounced visits
• Provide strategic leadership and support during survey processes to ensure optimal outcomes
• Deliver routine reports to quality and governance committees highlighting compliance status, problem-prone areas, and action plans

Education & Performance Improvement

• Develop and deliver formal and informal education programs across the healthcare team and support staff, fostering a culture of regulatory readiness and safe practices
• Demonstrate expertise in process improvement methodologies (PDCA, FMEA, etc.) and provide consultation to clinical and administrative teams
• Direct, facilitate, and coordinate the design and implementation of clinical quality and patient safety initiatives at business unit, regional, and system-wide levels
• Provide project management support to clinical improvement initiatives and share best practices across the organization

Operational Excellence & Leadership

• Manage associates and activities to ensure continuous compliance operations and service delivery
• Demonstrate strong analytical and problem-solving skills to develop effective systems and processes
• Exhibit innovation and forward-thinking approaches to drive positive outcomes and organizational advancement
• Maintain professional composure and demonstrate leadership excellence under pressure while managing complex, competing priorities
• Communicate with clarity, discretion, and confidence to influence and negotiate results with internal customers and external stakeholders
• Act as an organizational ambassador with external agencies, building and maintaining strong professional relationships
• Leverage information technology to communicate effectively, manage knowledge, mitigate risk, and support data-driven decision-making

Continuous Learning & Professional Development

• Stay current with accreditation standards, federal and state regulations, compliance best practices, and organizational policies
• Model ethical, honest, and professional behavior in all interactions and decision-making

Qualifications

** EDUCATION/EXPERIENCE REQUIRED:**

• Bachelor’s degree in Nursing or healthcare related field required , Master’s degree in health care field preferred; RN preferred
• Minimum 5 years hospital experience required; clinical/operational experience preferred
• Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required and familiarity with other accrediting, licensing and regulatory standards desirable.
• Evidence of continuing education in standards/regulations/training
• QI/PI Team member, lead or facilitator 1 – 3 years required
  • Scope: Broad Business unit/multidisciplinary team experience (working with several departments, and//or “deep” experience within one service line, value stream, etc)
  • Experience presenting to departmental, product line, and business unit leadership
• Knowledge of current healthcare issues and trends.
• Must meet or exceed core customer service responsibilities, standards and behaviors as outlined in the HFHS’ Customer Service Policy
• Must practice the customer skills as provided through on-going training and in-services.

Additional Information

** PHYSICAL DEMANDS/WORKING CONDITIONS :**

Normal office environment with minimal exposure to noise, dust, or extreme temperatures.