Quality/Accreditation Specialist II

About the role

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.

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.

Physical demands / Working conditions

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