QualityAccreditation Specialist II

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: 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.